Delivering health education to visually impaired older adults

State: CO Type: Promising Practice Year: 2016

Tri-County Health Department (TCHD), Colorado’s largest local public health department, serves 1.4 million residents, approximately 26% of Colorado’s population.  The population of TCHD’s three-county region is diverse, with urban and rural areas, and varies according to county.  Nearly one-quarter of TCHD’s residents are of Hispanic ethnicity (23%). Almost two-thirds (64%) are white, Non-Hispanic, five percent are Black/African American, five percent identify as Asian American/Pacific Islander or American Indian/Alaska Native. The remaining three percent identify as another race/multiple races.  As part of the multi-county Denver-metropolitan region, TCHD often partners with other governmental and community agencies from across the metropolitan area to support effective delivery of services on a regional basis.   Public Health Issue: The population of adults age 60 and older has grown significantly in TCHD’s jurisdiction and throughout the metropolitan region.  With older adult population growth has come an increase in need and demand for education and prevention services, particularly for fall prevention.  The significance of fall-related injuries to older adults' health status and the need for community  fall prevention efforts is increasingly documented and recognized in public health as well as in the health care system. In 2009, Colorado’s State Unit on Aging proactively expanded resources to support older adult fall prevention efforts.   With this support, Area Agencies on Aging (AAA) across the state implemented  A Matter of Balance: Managing Concerns About Falls—an evidence-based program designed to reduce the fear of falling, stop the falling cycle and increase activity levels among older adults.   The Denver Regional Council of Governments, the AAA for the Denver-metropolitan region, partnered with Tri-County Health Department to provide regional coordination and implementation of A Matter of Balance for the 8-county region.  As the regional coordinator, TCHD conducts outreach and works with community partners to deliver this proven fall-prevention program to a broad range of older adults, with particular focus on reaching vulnerable older adults and those who have had limited opportunity for prevention education.  In TCHD’s  A Matter of Balance outreach over the last two years, we experienced a steady increase in the numbers of older adults with sensory limitations, particularly vision impairments, who were not able to participate in the general class delivery structure. Given that visual impairment increases the risk of falls, it seemed imperative to find ways to provide fall prevention education to these vulnerable older adults.  In response, TCHD sought to identify and incorporate the needs of visually impaired participants in health promotion delivery structures, using the A Matter of Balance program as a pilot project.  Goals Goal 1: Develop competent health educators (both volunteer and employed staff) to deliver classes to visually impaired participants.  Goal 2: Effectively deliver fall prevention education to older adults with visual impairment in adapted A Matter of Balance classes that maintain fidelity to the evidence-based program structure.  Implementation/Activities To implement the project, TCHD identified and reached out to community resources who could offer expertise in developing class delivery structures adapted to the needs of the blind and visually-impaired.   We then collaborated with community partners to identify vision conditions most helpful for health educators to understand.  A sensitivity training curriculum was developed that included visual impairment simulation activities and general knowledge enhancement.  Staff and volunteer health educators from TCHD and community partners attended this training to increase understanding of challenges facing older adults with visual impairment and the implications for health education.  A list of class facilitation adaptations and facility modifications was developed and subsequently implemented in A Matter of Balance classes delivered to older adults with visual impairment.  Class materials and participant workbooks were re-formatted to accommodate large print versions as well as conversion to braille.  Four adapted A Matter of Balance classes were conducted in FY15 with 42 low-vision and blind participants. Results/Outcome: The project successfully improved the competence of health educators to deliver classes to visually impaired older adults; the trained educators subsequently delivered adapted classes to visually impaired older adults.  The learning results achieved by participants in the adapted classes were aligned with the evidence-based targets and were similar to those achieved in non-adapted general classes. Public Health Impact: Demands for services for an older adult population with sensory limitations will expand as this population increases in number. Health promotion efforts targeted at specific sub-populations is a means for public health to contribute to the health and well-being of our aging population in times of shrinking resources. Strategically designed training and education supporting unique needs of visually impaired older adults will have significant impact on fall and injury prevention.     
The risk of requiring hospitalization for a fall-related injury increases with age, and among older adults falls are the leading cause of injury deaths.  According to the Centers for Disease Control and Prevention, one out of every three older adults will fall each year.  In the Tri-County Health Department’s three jurisdictional counties, the combined average annual rate of hospitalization for fall-related injuries for the 65-74 age group was 709.6 per 100,000 population; for the 75-84 age group the rate jumps to 2,247.5 per 100,000 population. This compares with rates of 204.7 per 100,000 population for the 45-64 age group and only 72.8 per 100,000 for the 25-44 age group. [2008-2010]  The rate of fall-related deaths for adults age 60 and over has steadily increased in Colorado.  In 2004 the fall-related death rate for this age group was 42.9 per 100,000  population;  in 2014 it was 71.3 per 100,000– a significant increase over the last 10 years.  Clearly, this is a growing public health concern and developing effective fall prevention strategies and programs for this population is essential. Between 2010 and 2030 Colorado’s population age 65 and older is projected to increase by 150%, a significant shift in the state’s population demographics.  The 65-74 age cohort is projected to increase by 7% per year, much higher than the national average of 4.2% per year.  The largest segment of this older adult population resides in the Denver-metropolitan region. Tri-County Health Department (TCHD) is viewed as a leader in older adult fall prevention efforts because of its long history of convening community partners to address this increasingly concerning issue.  TCHD led a community collaborative that created The Fall Prevention Network (  as a community resource to address this problem. TCHD helped develop the infrastructure for region-wide delivery of evidence-based fall prevention programs, and has been the Regional Coordinating Agency for the delivery of A Matter of Balance: Managing Concerns About Falls in the Denver-metropolitan area since the program’s introduction into Colorado in 2009.    A Matter of Balance (MOB) is an evidence-based program that TCHD implemented regionally in keeping with the CDC’s guide, “Preventing Falls: How to Develop Community-based Fall Prevention Programs for Older Adults”   Each MOB class consists of eight 2-hour sessions held once a week for eight consecutive weeks.  Two volunteer certified MOB instructors (“Coaches”) co-facilitate the class.  Mentoring support and oversight is provided by a certified MOB Master Trainer from Tri-County Health Department. As the Regional Coordinator, TCHD created an effective, innovative regional structure and partnership model for program delivery across multiple jurisdictions.  TCHD manages this coordinated system for consistent program delivery across 8 metropolitan counties and provides fidelity oversight.  Program delivery is accomplished through long-term partnerships in the community with key community service providers who deliver the classes through congregate meal sites, senior centers, recreation centers, faith-based programs, city and county housing authorities, independent and assisted living facilities, and other local community gathering places for seniors.  As the population of older adults continued its rapid increase in the Denver-metropolitan region, and demand for the evidence-based A Matter of Balance classes grew, TCHD staff and our partners were increasingly challenged by growing numbers of older adults with vision impairments who could not effectively participate in classes as they are generally structured. We knew that the number of these older adults with sensory limitations was only going to increase with the growth of the older adult population.  Because of that, new approaches to outreach and health education were going to be needed to meet this unprecedented challenge.  We had previously reformatted the class materials to be available in large print and also created a version that allowed agencies to print the participant manuals in Braille.  Despite those efforts, few vision impaired older adults were participating and those that did still seemed to struggle.  This became the impetus to adapt the A Matter of Balance program and pilot new methods of class delivery to meet the needs of the visually impaired.  The pilot project adapting and delivering A Matter of Balance (MOB) for visually impaired older adults was implemented between July 1, 2014 and June 30, 2015.   A sensitivity training was developed and held at TCHD; 24 health educators from TCHD and community partners attended.   Four adapted MOB classes were delivered to 42 visually impaired older adults—two classes to 20 low-vision participants and two classes to 22 blind participants.  Since the pilot project completed, TCHD received funding from the Colorado Department of Public Health and Environment and their Administration for Community Living grant to deliver 10 additional  A Matter of Balance classes to this high risk population in FY16.  The program adaptations created to meet the needs of visually impaired older adults and the sensitivity training developed to build the skills of health educators working with this population are innovative practices.  TCHD established several unique community partnerships that include the Colorado Center for the Blind, the American Council for the Blind and Visually Impaired of Colorado, and older adult housing facilities.   Through these partnerships, the program was able to reach more vulnerable, high risk older adults who would not otherwise have had access to fall prevention education or who would not have been able to participate because of their visual limitations.   This practice improves the existing program by generating more effective outreach to a hard to reach population that TCHD and its partners were not previously reaching.  It improves work force development by teaching health educators skills needed to effectively teach vision-impaired participants, and it opens up access to much needed education for vulnerable older adults who up until now were unable to participate.   The practice also enhances the health department’s ability to increase access to important health education for underserved, vulnerable populations.  While the project focused on delivery of fall prevention education classes to older adults, the program adaptations and sensitivity training curriculum can be applied to other program delivery for visually impaired populations.   Health self-management, weight management, nutrition education, and smoking cessation classes are just a few of the programs that could be adapted to serve people of all ages for whom visual impairment is a barrier to accessing important educational support.  CDC Winnable Battle:  The practice addresses the Winnable Battle of Nutrition, Physical Activity, and Obesity.  The A Matter of Balance program is designed to increase activity levels among community-dwelling older adults by reducing the fear of falling and teaching easy to maintain exercises to improve strength and balance.   
The goals of the pilot project were to 1) develop competent health educators (both volunteer and employed staff) equipped to deliver classes to visually impaired participants and 2)  effectively adapt and deliver fall prevention education to older adults with visual impairment while maintaining the evidence-based curriculum and outcomes.  The following steps were taken to accomplish these goals: Identify and partner with community agencies to provide expertise on visual impairments and delivery of services to those who have them. Develop a sensitivity training curriculum for health educators to increase understanding of the challenges facing older adults with visual impairment and the implications for health education delivery. Develop adaptations to teaching methods using non-visual cues to accommodate visual impairments and build health educator’s skills in using them. Identify facility and class set-up adjustments needed to create safe physical environment for participants with visual impairment. Adapt delivery of A Matter of Balance classes to incorporate the identified teaching methods to accommodate the range of visual impairment while maintaining adherence to the evidence-based curriculum. Adapt and reformat class materials and participant manuals to a large print format; reformat materials and manuals to allow conversion to braille. Deliver a training session to A Matter of Balance instructors and other health educators including the sensitivity training curriculum, practice of adapted teaching methods, and review of reformatted materials. Collaborate with partners to provide community facilities to hold A Matter of Balance classes for visually impaired older adults, provide outreach to visually impaired older adults, and recruit participants for the scheduled classes. Deliver A Matter of Balance classes with the adapted teaching methods and physical environment adjustments to participants with a range of visual impairment. Track participant satisfaction survey data, and pre-post class self-assessment data; compare adapted visually impaired class data with non-adapted general population class data. A key factor leading to the success of the practice was collaborative partnerships with community agencies that have expertise in meeting the needs of visually impaired older adults, and with progressive older adult housing facilities who recognized the value both to their residents’ quality of life as well as the business revenue protection of reducing the dramatically increased fall-related injury risk of their visually impaired residents.  Tri-County Health Department partnered with three key community providers to accomplish all of the listed steps:  Colorado Center for the Blind;  American Council for the Blind and Visually Impaired of Colorado; and Brookdale Senior Living Communities.  These partners were part of an advisory team offering their expertise to identify the most common vision issues among older adults and the specific impact these vision issues have on activities of daily living and on adult learning.  TCHD and this advisory team collaboratively developed a curriculum for a sensitivity and skill-building training for health educators. Training Curriculum and Activities Didactic Learning:  Clinical description of the identified vision conditions and the potential impact on a person’s ability to manage activities of daily living.  These include: low vision with some correction through glasses; cataracts; glaucoma; macular degeneration; retinopathy related to diabetes; detached retina; and heminopsia. Simulation Activities: Tasks using simulation glasses to model all of the identified vision issues.  Training participants were asked to do simple tasks while wearing each set of simulation glasses. Dyads/Triads:  Scenarios provided to training participants in dyads and triads to experience being the older adult with visual impairment. Dyad/triad participants rotated through the roles of being the person with visual impairment, the person supporting the visually impaired person, and (for triads) being an independent observer to provide feedback. Etiquette Lessons:  Interactive discussions on the etiquette for assisting people with visual impairment and being around service dogs.  Presenters who have visual impairment themselve facilitated the discussions. Teaching/Facilitation Adaptations:  Demonstration and practice of teaching method modifications to enhance learning for the visually impaired.  These include adaptations to: materials; methods of communication and non-visual facilitation cues; activity demonstration; and classroom set up among others. Facility Adaptations:  Description of modifications to the facility that create a safer learning environment for the visually impaired.  These include consistent room set-up, wider pathways, good lighting, and availability of greeters among others. A sensitivity and skill-building training session using this curriculum was held at Tri-County Health Department for the pilot project. Instruction and facilitation of the curriculum was a shared among the advisory team partners.  Twenty four health educators from TCHD and community partners attended. Additional roles of the partners included identifying where populations of visually impaired older adults live and gather, supporting TCHD in providing outreach to them, and recruiting/registering participants for the A Matter of Balance classes.  Partners provided their own facilities to hold the MOB classes or made arrangements with other community facilities with whom they had existing relationships.  Four adapted MOB classes were delivered to 42 participants. Two of the classes were delivered to older adults with a range of visual impairment (20 participants).  All participants had vision impairment issues documented in the records kept by their assisted living facility.  All lived in separate apartments on the facility’s grounds and participated in congregate meals at the facility. Two of the classes were delivered to older adults who were legally blind (22 participants).  All lived in independent residences throughout the community and all were day students who came to the Colorado Center for the Blind to attend independent living trainings. Costs: The main cost of this project implementation is staff time for partnership development, curriculum development, delivery of the sensitivity training class, and coordination of MOB class delivery.  This staff time was not an additional expense for this project as it was incorporated into TCHD’s existing Program Coordinator FTE.   Direct class delivery costs are the same as they are for all A Matter of Balance classes delivered through the TCHD regional structure.  The class cost of $800 per class assumes a full class of 14 participants and includes all participant materials, teaching supplies, participant incentives, healthy snacks, staff mileage, host stipend (to cover partner’s staff time and expenses), and a stipend for volunteer instructors.  Per class costs are less with fewer participants.  Often the host stipend and volunteer stipends are not necessary, reducing the cost further.    
Goal 1 of the project was to develop competent health educators (both volunteer and employed staff) equipped to deliver classes to visually impaired participants. Twenty-four health educators were trained using the project’s sensitivity and skill-building curriculum.  Feedback solicited from Master Trainers, Instructors (Coaches), participants and facility managers indicate that the advance sensitivity training and the implementation of the identified adaptations were effective and important in preparing both the facilities and the instructors to meet program delivery needs of the visually impaired.  GOAL 2 of the project was to effectively adapt and deliver fall prevention education to older adults with visual impairment while maintaining the evidence-based curriculum and outcomes.  The participant satisfaction survey results combined with the pre-post self-assessment results suggest that the adapted classes for visually impaired older adults are effective and have a similar impact as the non-adapted classes delivered to the general population of older adults.  Participant Satisfaction Survey: All 42 participants in the pilot project classes completed a satisfaction survey at the end of the 8-session class.  Two key measures of success for A Matter of Balance and fall prevention is participants’ reported comfort level with talking to others about their fear of falling and a reported increase in activity levels as a result of the class.  In the pilot project, over 88% of the visually impaired participants completing the survey responded with positive indicators for both.  This suggests positive impact of the adapted classes.  Satisfaction survey results from the classes adapted and delivered to visually impaired older adults were compared to the survey results from 121 survey respondents in the non-adapted classes delivered to the general older adult population during the same time period (July 1, 2014 – June 30, 2015).  Results were similar between the two cohorts with one notable exception.  A lower percentage of visually impaired respondents reported making changes to their environment as a result of the class (64% of visually impaired respondents compared to 91% of general respondents).  Pre-and-Post Self Assessment:  Participants were also asked to complete a self-assessment at the first and last class sessions regarding several fall prevention indicators standardized for the A Matter of Balance program.  Results were analyzed for all participants who completed both pre and post self-assessments using the standard A Matter of Balance program metrics for indicating rate of positive change.  There was positive change in all metrics for both the visually impaired cohort and the general population cohort.  The rate of positive change in some indicators (i.e., “I can protect myself if I fall”; “I can find a way to get up from a fall”) was lower for visually impaired respondents compared to the general population.  However, for all indicators there was a significant number of visually impaired respondents who moved from a response of “not sure/somewhat sure” on the pre-assessment to “sure/very sure” on the post-assessment.  Rate of positive change—i.e., participants self-reporting neutral or positive change in response to the pre-post survey questions—are shown below:      SURVEY QUESTION                                                               % POSTIVE CHANGE                             % POSTIVE CHANGE                                                                                              Low vision/Blind   N=27                              General     N=121 1.  I can find a way to get up if I fall                                                   78%                                                        89% 2.  I can find a way to reduce falls                                                      89%                                                        92% 3.  I can protect myself if I fall                                                            81%                                                        95% 4.  I can increase my physical strength                                                96%                                                        92% 5.  I can become more steady on  my feet                                           89%                                                        89% 6.  Concern for falling interferes with normal      social activities with groups/family/friends                                      89%                                                        81% 7.  Current exercise                                                                           96%                                                        92%                        Some differences exist between the responses of the visually impaired cohort and the general population cohort, but those differences seemed aligned with what might be expected of older adults who are challenged by having fewer visual cues to help them.  The result fewer visually impaired participants reported that they made changes to their environment to reduce fall risk may be due to the fact that they are living in places adapted to their lack of vision and many safety adaptations have already been made.       
What we learned:  Sensitivity training and the implementation of the adaptations are effective and important in preparing both the class facilities and the instructors to meet program delivery needs of the visually impaired.  Teaching methods can be adapted and readily taught to both volunteer and employed staff to enhance public health education delivery to low vision and blind participants. Making it safe and easy for visually impaired participants to let class instructors know what they need to support their participation is important in order to adapt to emerging or unanticipated needs.  Indications are that, with proper adaptations, fidelity with the evidence-based curriculum can be maintained and classes can be delivered with similar impact as non-adapted classes. Observable physical limitations were more common in the visually impaired groups than the general population. While this may not be found in every visually impaired group,  the use of canes, walkers, and wheelchairs coupled with a range of significant visual impairment needs to be anticipated and supported with additional facility and set-up accommodations to the degree feasible.  Development of a workforce better equipped to inform and educate high risk older adults to prevent falls is critical.  As a result of this pilot project, sustainability of fall prevention education to visually impaired older adults has been established for the next two years.  The funding received through the Colorado Department of Public Health and Environment supports multiple classes for FY16, and an increase in primary A Matter of Balance funding from the AAA is allowing us to bring continued outreach and MOB classes to visually impaired older adults for at least two years.  An additional partnership with the American Council for the Blind and Visually Impaired of Colorado(ACBCO) was formed subsequent to the pilot project.  TCHD and ACBCO are working together to bring one- hour fall prevention education sessions and nutrition education sessions to visually impaired older adults.  The principles developed as part of this project were shared with TCHD’s nutrition staff who used them to adapt an evidence-based cooking and kitchen safety class for delivery to this population as part of this partnership. The enhanced relationships with partners serving the visually impaired population, as well as with the visually impaired older adult community itself, is allowing us to more effectively reach out to this often invisible, harder to reach population.  Plans are to continue to evolve our understanding and effectiveness in adapting programs, incorporate additional training for our health educators to serve this population, and continue to leverage the good will and confidence in TCHD’s leadership to bring additional resources and partnerships to the table.   
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