Unintentional falls are a significant predictor of illness and death in older adults (1-4). Evidence suggests that 1 in 3 older adults in the United States falls at least once each year (1-4). According to the Centers for Disease Control and Prevention (CDC), approximately 30% of the total number of people with a recorded fall in 2009 were aged 60 years or older (5). Among older adults, unintentional falls are the most common cause of all nonfatal injuries (1,2,4,6-8).

In addition to actual falls, many people experience a fear of falling. Lach (9) found an adjusted prevalence of 30.6 per 100 for fear of falling in older adults, which increased to 47.2 over 2 years. People who have a fear of falling are twice as likely to fall compared to those without. They also experience more anxiety and social isolation (10). Furthermore, fear of falling can affect quality of life (11,12) through restricted activities and increased frailty, leading to poorer health outcomes (13).

The primary goal of A Matter of Balance (MOB) and its Spanish equivalent, Un Asunto de Equilibrio (ADE), is to empower people who have fallen or who fear falling with a sense of control over falls. Expected outcomes include increased activity levels and improved mobility. The program uses cognitive strategies to address the factors associated with falls in older adults (14). Although the success of MOB has been documented (15,16), no evidence has been published for ADE. Additionally, results that correspond with the adoption and practical application of these programs by community-based agencies are lacking. Therefore, the primary objective of the study was to evaluate the success and effectiveness of the lay leader model of both MOB and ADE in community-based settings in South Florida. A secondary objective was to further report on participant outcome measures for MOB and to report ADE outcome measures for the first time.

A total of 958 older adults participated in either an MOB (n = 275) or ADE (n = 683) workshop. Based on inclusion criteria, 396 participants were excluded, leaving a sample of 562; (MOB, n = 160; ADE, n = 402). Of these, 538 were completers (Box). We did not find any significant demographic differences between excluded and included participants.

More women than men participated in both MOB and ADE (Table 1). Most MOB participants were non-Hispanic white, and most ADA participants were Hispanic. Few MOB participants but more than half of ADE participants reported an annual household income less than $15,000. Neither program attracted many participants who saw themselves as frail or disabled.

For both MOB and ADE, the FMS score increased significantly for each item at posttest (Tables 2 and 3). A significant increase in the posttest mean of the PACE measure in both study groups suggests that after attending the MOB and ADE workshops, participants' readiness to include exercise in their daily routine increased. We also found significant changes in mean for the social activity measure for participants in both groups.

One hundred and fifteen MOB participants and 276 ADE participants completed the evaluation questionnaire, a 72% and 69% response rate, respectively. All respondents either strongly agreed or agreed that the programs were effective, beneficial, and well organized. Most respondents (MOB, 87%; ADE, 89%) agreed that the instructors were well prepared for the class and the participant workbook helped them better understand the classes. Most participants (MOB, 84%; ADE, 86%) said that they would recommend the program to a friend or relative.

Overall, our findings suggest that community agencies were able to implement MOB and ADE and achieve desired participant outcomes. The number of MOB participants reached in our study is higher than in another falls prevention randomized controlled trial (16) but lower than a recent community-based study of MOB that used a volunteer lay leader model (15). No published study has reported evaluation findings on ADE.

Each agency that implemented MOB or ADE met their proposed goals of participant reach and number of workshops to be offered. In addition to increasing capacity for continuation of the MOB and ADE programs, the master and lay leader trainings represent a successful collaborative effort to share training responsibilities and make maximum use of available resources. The significant changes in program outcomes and the success of implementation as indicated by participant evaluations and fidelity observations, while not under research controls, provide further support for the effectiveness of the lay leader model of MOB. These study findings are similar to those reported elsewhere (15).

Participants significantly changed their attitudes about falling after completing the program. The significant change between baseline and posttest FMS scores indicates that the content and design of the programs helped participants increase their level of self-confidence in their ability to control falls and manage fear of falling. Other studies that assessed these outcomes in controlled settings and in community-based settings found similar results (15,16). Furthermore, change in a person's attitude toward sense of control over falls can lead to improvement in everyday function and engagement in low-impact physical activity, enhancing quality of life. Our interpretation is supported by other studies (20,21) that found that older adults who reported low control over falls also reported greater declines in ability to perform activities of daily living.

The PACE measured participants' comprehension of the importance of exercise and affirmation of readiness to perform and include exercises in their daily routines. Similar to other measures, PACE results also showed significant improvement for participants in both programs. Healy et al reported similar findings (15). Other studies document additional benefits of this attitude change toward exercise. These studies suggest that involvement of older adults in some kind of exercise helps to reduce rates of illness and death for many chronic conditions such as hypertension, stroke, diabetes, and obesity (20-22).

Overall, results showed changes from baseline to posttest in social activity scores for both MOB and ADE participants, although the change in mean of 0.12 for MOB participants is smaller than the 0.26 change documented in another community-based falls prevention program (15). The social activity item measures the degree to which participants believed that fear of falling interfered with their daily activity and ultimately reduced social activity, both of which have a well-established relationship with fear of falling (23,24). One study documented increase in anxiety and depression as the negative consequences of social isolation for older people (25). Therefore, the improvement on this item for both MOB and ADE suggests that this initiative was successful.

Our outcomes are consistent with those of previous MOB studies (15,16,26). Moreover, the positive and significant results in all ADE measures, and the large number of ADE participants, indicate that the Spanish version of the program was well received and that outcomes were consistent with those published for MOB.

This study has several limitations. First, it has limited generalizability because findings are for programs offered in South Florida. The agencies that offered the programs, and program participants, may not be representative of agencies and participants in other communities. Second, because the evaluation design had no control group, participant results may reflect other treatments or historical events. Third, participants were not randomly selected but rather volunteered because they thought they might benefit from the program. Therefore, selection bias may have skewed results. Similarly, all data collected were self-reported and therefore subject to response and social desirability biases. Finally, because of funding limitations and the fact that MOB had previously been deemed effective in reducing falls, data regarding actual falls before and after program participation were not collected (14-16,26,27). Future studies that look at the effect of covariates and moderator variables on outcome data and predictive factors are needed.

In summary, successful implementation of MOB and ADE through the Healthy Aging Initiative demonstrated that local capacity could be established to offer falls prevention programs to older adults in community settings. The model used by the Healthy Aging Initiative can be replicated by other communities that identify a need for falls prevention programs for older adults to improve their quality of life and to reduce the burden on the health care system. Our results support the premise that, when trained properly, lay leaders can implement evidence-based programs effectively, which opens the possibility of implementing such programs on a wider scale and with less cost in many locations in the United States.