Statewide Prevalence of Stepping on, Tai Chi, and a Matter of Balance Community Fall Prevention Programs at Maryland Senior Centers in 2017 and 2020

The Centers for Disease Control and Prevention (CDC) recommends evidence-based Community Fall Prevention Programs (CFPPs) to prevent fall-related injury in older adults [1]. Though access to healthcare is one of the five key areas of social determinants of health, little is known about the offering of CFPPs at Senior Centers (SCs). Prior studies indicate that Stepping On (SO), Tai Chi (TC), and A Matter of Balance (MOB) may be the most common CFPPs at SCs in the US. Prior prevalence literature only examined rural areas [2], or medical center vicinity [3], and did not assess trends over time. The current study assesses statewide availability of SO, TC and MOB in 2017 and 2020 (prior to the COVID19 pandemic) to help better understand access to CFPPs in Maryland.

Participants 

111 SCs across the 24 counties listed in Maryland Department of Aging’s 2015 Database [4] were studied. Nursing homes, assisted living facilities, adult day care centers and community wellness programs were excluded.

Study design and survey method 

We conducted telephone-based surveys in December 2017 and January 2020 to gather the data. SC telephone numbers were obtained from the 2015 Database [4] and were contacted on weekdays during normal business hours. SCs were excluded if no point of contact was established after three attempts on separate days. We did not differentiate between different types of TC interventions e.g., Tai Chi for Arthritis (TCA) or Tai Ji Quan: Moving for Better Balance (TJQ), since telephone operators only referred to any of these programs as TC. After reaching a SC, the telephone operator was asked two questions: 1) “For geriatrics, what fall prevention programs do you offer?;” and 2) “Does your senior center offer SO?, TC?, or MOB?” If the SC representative requested clarification, we detailed the nature of these programs.

Data measurement 

For each question, presence or absence of the three CFPPs queried was noted for each SC in 2017 and 2020.

Additional measures 

Median county income (in dollars), county population, and proportion of seniors (>65 years old) for each of the 24 counties were obtained from the 2016 and 2018 US Census Bureau Quick Facts [5]. We hypothesized that these variables may play a role in the prevalence and underreporting of SO, TC and MOB.

Statistical analysis 

Descriptive statistics were used to analyze the survey results, and univariate and multivariate logistic models were used to analyze our additional measures. Statistical analysis was performed using R: A Language and Environment for Statistical Computing, version 3.6.3, available at http://www.R-project.org (The R Foundation for Statistical Computing). P values were 2-sided at .05 significance.

Across the 24 counties in Maryland, 107 SCs were contacted in December 2017 and 111 in January 2020. 76.6% of SCs offered at least one of these three CFPPs in 2017 but only 56.8% in 2020, a statistically significant decrease of 19.9% (95% CI 6.7% to 33.0%; P=.003). TC was offered in 70 SCs (65.4%) in 2017 and 61 (55.0%) in 2020 (95% CI 3.4% to 24.3%; P=.15). SO offering significantly decreased by 18.9% (95% CI 8.6% to 29.2%; P <.001) from 27 SCs (25.2%) in 2017 to 7 (6.3%) in 2020, whereas MOB by 9.4% (95% CI 2.0 to 16.8%; P=.01) from 12 SCs (11.2%) in 2017 to 2 (1.8%) in 2020 (Figure 1). Table 1 demonstrates that there is both regional and temporal variation in offering these CFPPs. Univariate analysis yielded association between SO prevalence and median county income (P=.05); TC prevalence and median county income and county population (P <.001 and P=.004). Multivariate analysis showed that TC prevalence maintained its association with median county income and county population (P <.001 and P=.001). In both analyses, MOB prevalence was associated with county population (P=.05 and P=.04). 

Figure 1: Prevalence of Tai Chi and stepping on programs per Baltimore County in 2017 and 2020.

County abbreviations: A: Allegany, B: Anne Arundel, C: Baltimore City, D: Baltimore County, E: Calvert, F: Caroline, G: Carroll, H: Cecil, I: Charles, J: Dorchester, K: Frederick, L: Garrett, M: Harford, N: Howard, O: Kent, P: Montgomery, Q: Prince George's, R: Queen Anne's, S: St. Mary's, T: Somerset, U: Talbot, V: Washington, W: Wicomico, X: Worcester 

Table 1: Telephone survey results collected in 2017 and 2020 by Maryland County.

*Total number of senior centers which offer the program.

N/A values are indicated for counties where the specific fall prevention program was not offered that year

Abbreviations: SC: Senior Center; SO: Stepping On, TC: Tai Chi, MOB: A Matter of Balance 

Overall, telephone operators did not volunteer availability of CFPPs 72.5% in 2017 and 95.7% in 2020, a statistically significant increase of 23.2% (95% CI 12.4% to 33.0%; P<.001) (Figure 2). SO was underreported by 66.7% of SCs in 2017 and 100% in 2020 (95% CI6.6 to 60.1; P=.19). TC was underreported by 71.4% of SCs in 2017 and 95.1% in 2020, a statistically significant increase of 23.7% (95% CI 10.2 to 37.1; P<.001). MOB was underreported by 91.7% of SCs in 2017 and 100% in 2020 (95% CI -15.6 to 32.3; P>.99). In both univariate and multivariate analyses, TC underreporting was associated with median county income (P <.00 and P <.001) and county population (P=.02 and P=.01).

Figure 2: Aggregate underreporting rates of Tai Chi, stepping on, and a matter of balance programs per Baltimore County in 2017 and 2020. 

County abbreviations: A: Allegany, B: Anne Arundel, C: Baltimore City, D: Baltimore County, E: Calvert, F: Caroline, G: Carroll, H: Cecil, I: Charles, J: Dorchester, K: Frederick, L: Garrett, M: Harford, N: Howard, O: Kent, P: Montgomery, Q: Prince George's, R: Queen Anne's, S: St. Mary's, T: Somerset, U: Talbot, V: Washington, W: Wicomico, X: Worcester

Though CFPPs are part of the CDC’s fall prevention algorithm [1], this is the first study to 1) provide a statewide survey of CFPPs at SCs; 2) assess for change in prevalence over time; and 3) document that telephone operators underreport CFPPs which they know to be offered. The current study examined the three nationally most common CFPPs [2,3] and found that at least half of the SCs offered at least one of them in 2017 and in 2020. That said, the prevalence of these programs decreased by 20% by 2020, even before the onset of the COVID19 pandemic, which caused closures of SCs nationally. 

Our results indicate that there are regional and temporal variations. An older adult in Maryland who inquires about such programs at two senior centers is likely to find at least one of the three CFPPs. CFPP statewide prevalence data, combined with a clinical referral algorithm (e.g., Hamel et al., [6]), can help physicians more efficiently guide older adults to the local SC offering the appropriate CFPP. If our findings-which show significant temporal and geographical variation in the offering of CFPP-are nationally representative, then real-time online platforms should be developed to help clinicians direct patients to the SC offering the CFPP best suited to their needs. 

Unfortunately, we found that making a phone call to inquire about these programs oftentimes results in receiving misleading information. In over 70% of cases, telephone operators at SCs who knew that a particular CFPP was offered failed to volunteer this information when asked about fall prevention programs at their facility. Now, amid further dissemination of the COVID19 vaccine and the positive prospects of opening SCs soon, a public health initiative may be undertaken to ensure that SC phone operators properly inform customers about the availability of their CFPPs. A national study on CFPP prevalence in SCs across the US near medical centers found that the most common CFPPs are (1) TC, (2) MOB and (3) SO [3]. A national rural-based study found that the most common CFPPs are (1) MOB, (2) SO and (3) TJQ (a type of TC) [2]. Our results indicate that the TC prevalence in Maryland is consistent with trends near medical centers and surpasses rural trends, and that MOB was not well represented in Maryland. 

Limitations include only examining 3 CFPPs at SC in only one state and not differentiating between different types of TC. Although SCs are the most common places where CFPPs are delivered [7], our study did not evaluate other venues that may offer these programs. Additionally, this study only evaluated inquiries over the phone, whereas SCs may also communicate their programs in other ways, e.g., email. CFPP availability landscape may change in the post-COVID19 era. In summary, at least 50% of SCs offer CFPPs. There are geographical and temporal variations in CFPP offering, with a downward trend in Maryland. Telephone operators at SCs in Maryland do not commonly volunteer information about CFPP availability.

Acknowledgment 

Ilan Lavian, New York University School of Law, provided comments and edits on the manuscript; Chaniesa Burnett, Steady Strides: Fall Prevention and Stroke Rehabilitation Medical Institute, assisted with data collection.

Conflicts of Interest 

The authors have no conflicts of interests to declare.

Funding sources 

The authors have no funding sources to declare.

Author contributions/commitments 

LA: Study concept and design

NH, CH, DNY, MZ, BS, ME, LK, MN, MT, and LA: Acquisition of data, analysis and interpretation of data

MT: Statistical analysis

NH and CH: Preparation of manuscript

NH, CH, DNY, MZ, BS, ME, LK, MN, MT, and LA: Read and approved the final manuscript

Data Deposition: Not needed, Table 1 included