CAPSTONE-FINAL-5-11-15

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STEPPING ON: A PROGRAM EVALUATION OF SHORT-TERM OUTCOMES
A Program Evaluation Presented to
The Faculty of the Department of Occupational Therapy
San Jose State University
In Partial Fulfillment
Of the requirements for the Degree
Master of Science
Rustyn Mooney, Isaac Pollard, Lynn Tse, Paulina Urrutia, Asa Williams
May 2015

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APPROVED FOR THE DEPARTMENT OF OCCUPATIONAL THERAPY
______________________________________________
Deborah J. Bolding, PhD, OTR/L

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STEPPING ON: A PROGRAM EVALUATION OF SHORT-TERM OUTCOMES
By Rustyn Mooney, Isaac Pollard, Lynn Tse, Paulina Urrutia, Asa Williams
Abstract
Background/Rationale: Falls are the leading cause of nonfatal and fatal injuries among older
adults, which may lead to a decrease in independence and quality of life. Stepping On is an
evidence-based, multifactorial falls prevention program designed to increase self-efficacy and
promote safe behaviors in older adults. The purpose of this study is to evaluate the effectiveness
of the Stepping On program by analyzing four outcomes including: self-efficacy, increased
strength, reduction of fall risk, and the perceived value of the program.
Method/Approach: Secondary data analysis was conducted on archived data of Stepping On
program participants in Santa Clara County sponsored by Stanford Healthcare between 2013 -
2015. The method of data collection was through self-reported questionnaires given to the
subjects during the first session of the program, the last session and at the three-month booster
session of the program. The sit-to-stand standardized test was used to quantitatively collect data
on subjects’ lower body strength.
Results: The results demonstrated that there was a positive perceived value of the class, a
significant increase in lower body strength and a decrease in fall risk. There were no significant
changes in self-efficacy.
Conclusions/Implications: The results suggest that Stepping On is an effective multi-factorial
program in fall prevention, given that three of the four outcomes had a positive change.
However, program improvements could be made in these areas: outcome measurements, follow-
through with participants, and expanding the population being served.

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Acknowledgments
We would like to thank Dr. Deborah Bolding for her support, guidance and collaboration
on this program evaluation. We appreciate her willingness to work with us, and the positive
feedback she gave us at each step of this project. We would also like to thank Dr. Megan Chang
for her invaluable input and guidance on the statistical analysis of our data. Finally, we would
like to thank Stanford Healthcare for partnering with us in this program evaluation.

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Table of Contents
Chapter I: Introduction……………………………………………………………………………1
Background and Purpose………………………………………………………………….1
Limitations, Implications, and Question…………………………………………………..1
Definitions………………………………………………………………………………....2
Chapter II: Literature Review……………………………………………………………………..5
Risk Factors and Fall Prevention Programs……………………………………………….5
Stepping On……………………………………………………………………………….8
Components of the Stepping On Program……………………………………….10
Conclusion……………………………………………………………………………….16
Chapter III: Methods……………………………………………………………………………..17
Participants……………………………………………………………………………….17
Materials and Instruments………………………………………………………………..18
Program Evaluation Data Collection…………………………………………………….19
Data Analysis…………………………………………………………………………….20
Chapter IV: Results………………………………………………………………………………22
Introduction………………………………………………………………………………22
Participants……………………………………………………………………………….22
Outcomes………………………………………………………………………………...23
Self-efficacy……………………………………………………………………...24
Participant Valuation…………………………………………………………….25
Lower Body Strength…………………………………………………………….25
Reduction of Fall Risk…………………………………………………………...26

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Chapter V: Discussion…………………………………………………………………………...28
Demographics……………………………………………………………………………28
Outcomes………………………………………………………………………………...29
Self-efficacy……………………………………………………………………...29
Valuation…………………………………………………………………………30
Sit-to-Stand………………………………………………………………………30
Reduction of Fall Risk….………………………………………………………..31
Conclusion……………………………………………………………………………….31
References………………………………………………………………………………………..33

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Chapter I: Introduction
Background and Purpose
Older adults are at greater risk of falling and sustaining fall-related injuries than any other
age group (Boye et al., 2013; Stevens, Corso, Finkelstein, & Miller, 2006). Falls and fear of
falling have serious ramifications for older adults, including decreased mobility, lack of
confidence, dependent living, and depression– all of which can lower their quality of life by
depriving them of meaningful occupations (Boye et al., 2013). Due to the severity and long-term
recovery of falls in older adults, fall prevention is essential for their long-term health and well-
being. To address this problem, several factors must be considered when planning and
implementing an effective fall prevention program. These factors include intrinsic elements such
as muscle weakness, poor vision, and medication side effects, along with extrinsic elements such
as environmental safety hazards.
The National Council on Aging (2015) recognizes several evidence-based fall prevention
programs for older adults. These include both single-intervention programs, such as exercise or
Tai Chi, and multifactorial programs that address multiple factors linked to falls. Multifaceted
approaches to fall prevention have demonstrated significant reductions in fall risks (National
Center for Injury Prevention and Control, 2008). One such program, Stepping On, is a
multifactorial, community-based program that addresses multiple intrinsic and extrinsic risk
factors. This program aims to improve fall self-efficacy, encourage behavioral change, and
reduce falls among older adults.
Limitations, Implications, and Question
The aim of this program evaluation is to examine the effectiveness of the Stepping On
program when considering these short-term outcomes: self-efficacy, improved lower body

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strength, reduction of fall risks, and the perceived value of the program. The findings from this
program evaluation will help determine changes in services and programs offered by a
community falls prevention program.
The primary limitation of this evaluation is that short-term outcomes may not provide
sufficient data to demonstrate statistically significant results when in fact there may be. This is
due to the multifactorial nature of Stepping On. The measurement used in testing lower body
strength is standardized and straightforward, but it may be more difficult to ascertain the full
effect that the participants’ behavioral changes may have had on fall reduction. Also, the
questionnaires used to assess the short-term outcomes of self-efficacy and perceived value are
not standardized, so participants’ responses may not be valid and reliable. Although there are
limitations, this evaluation will contribute evidence by answering this question: is Stepping On
an effective multifactorial fall prevention program when observing short-term outcomes in
strength, self-efficacy, fall reduction, and perceived value?
Definitions
● Older adults- Although there is no general agreement on the age in which someone
becomes an older adult, most developed nations accept the chronological age of 65 years
as elderly or old age (WHO, 2015). The United Nations recognizes old age at 60+ years.
For our evaluation, we will use the age of 60+ when referring to the older adult
population.
● Fear of falling- A “lasting concern about falling that can lead an individual to avoid
activities that he/she remains capable of performing” (Tinetti, Richman, & Powell, 1990,
p. 239).

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● Fall- One definition is “an event which results in a person coming to rest unintentionally
on the ground or other lower level, not as a result of a major intrinsic event (such as
stroke) or overwhelming hazard” (Tinetti, Speechley, & Ginter, 1988, p. 1702). The
World Health Organization (WHO) (2007) defines a fall as “an event which results in a
person coming to rest inadvertently on the ground or floor or other lower level excluding
intentional change in position to rest in furniture, wall or other objects” (p. 1).
● Fall risk- Risk is an exposure to harm or injury (Merriam Webster’s, 2015). In relation to
falls, risk is measured by possible causes of falls for which there are no agreed upon
classification. The Effective Health Care Bulletin (1996) recognizes five fall risk
categories: environmental, medication-based, age-related (e.g. vision loss, cognitive
impairment), nutritional (e.g. insufficient calcium or vitamin D), and physical activity-
related.
● Self-efficacy- How one uses his or her capacity to impact what happens in life is called
self-efficacy; it includes perceptions of self-control and the ability to achieve one’s
desires (Kielhofner, 2002).
● Multi-factorial- The National Center for Injury Prevention and Control (2008) defines
this term as a multifaceted intervention that combines exercise with other intervention
components to reduce fall risk factors. Such a program might include exercise, vision
assessment, and fall prevention education.
● Home modification- Home modification is defined as identifying and modifying home
hazards that can increase older adults’ risk of falling (National Center for Injury
Prevention and Control, 2008). The recommendations for modifications are frequently
made by an occupational therapist, but the individual does the actual modification.

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● Medication management- The National Center for Injury Prevention and Control (2008)
defines this term as adjustments or changes to medications while under the care of a
pharmacist or healthcare provider. Drug side effects and interactions are addressed as
related to falls.

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Chapter II: Literature Review
Falls are reported as the leading cause of death among the older adult population (Boye et
al., 2013). This is an alarming statistic, as approximately one third of older adults fall at least
once each year (Boye et al., 2013; National Center for Injury Prevention and Control, 2008). The
probability of an injury from a fall increases with age. Hip fractures are the most common injury,
with studies indicating roughly one third of older adults who sustained a hip fracture died within
a year of their injury (Boye et al., 2013; Stevens, Corso, Finkelstein, & Miller, 2006). Falls are
also the leading cause of traumatic brain injuries (TBIs) among older adults (Stevens, Corso,
Finkelstein, & Miller, 2006). Fall-related injuries can significantly impact an individual’s quality
of life by causing lifestyle changes, isolation, and occupational deprivation, underscoring the
need for fall prevention programs that address the health care needs of the older adult population.
Multifactorial programs, such as Stepping On, target common fall risk factors and
behaviors while promoting self-efficacy among participants (National Center for Injury
Prevention and Control, 2008). This literature review outlines fall risk and falls prevention
programs in general; the Stepping On program; fall risk factors addressed by the program; and
how Stepping On is suited to occupational therapy practice and the Model of Human of
Occupation (Kielhofner, 2002). This chapter will discuss risk factors related to falls and fall
prevention programs, the specific components of Stepping On, and information regarding the
program’s effectiveness.
Risk Factors and Fall Prevention Programs
According to the National Center for Injury Prevention (2008), as one ages, the risk of
falling increases. Three categories of risk factors have been identified, including behavioral,
biological, and environmental factors. Biological risk factors include muscle weakness, balance

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impairment, and vision loss. These factors can contribute to the behavioral risks posed by
inactivity and medication side effects, increasing an older adult’s risk of falling. Environmental
risk factors include home hazards (i.e. throw rugs, poor lighting) and the incorrect use of
assistive devices while navigating in the environment. Older adults are often unaware of these
risks, and falls occur due to a combination of risk factors (National Center for Injury Prevention,
2008). Therefore, fall prevention programs that target multiple factors are more likely to address
the particular risks faced by a given participant. To combat these risks, fall prevention programs
should address fall prevention education, exercise, medication management, home modification
and safety, and vision assessment.
Multifactorial programs have been gaining support as demonstrated by the Centers for
Disease Control and Prevention’s (2008) recommendations that fall prevention programs address
all the risk factors that can lead to falls. A holistic approach was advised for managing the health
care of the older adult, as there is often a demand for examining a multitude of needs and factors
in the aging person (Day, 2013). A multifactorial intervention assesses the various risk factors,
provides an opportunity for coordinated care, and collaborates between healthcare providers
integrating with existing care. Thus, programs like Stepping On operate with existing resources
and may be better suited than single interventions in addressing the multitude of factors
associated with falls.
The National Council on Aging (2014) recommended several evidence-based falls
prevention programs in addition to Stepping On, including: A Matter of Balance, FallScape,
Otago Exercise Program, Stay Active and Independent for Life, and Tai Ji Quan: Moving for
Better Balance. The most similar to Stepping On, A Matter of Balance (MOB) is another
multifactorial, community-based falls prevention program that is widely recognized and

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implemented. However, Stepping On includes a home visit to address home safety
modifications, a follow-up telephone interview, and a booster session three months after the
program conclusion. Additionally, Stepping On utilizes guest experts, such as a physical
therapist, an occupational therapist, a pharmacist, a vision expert, and a community mobility
expert. In contrast, MOB hosts a one-time guest therapist during the length of its course.
Other fall prevention programs are not as comprehensive as Stepping On or MOB.
FallScape is a personalized one-on-one behavioral program that includes an individualized
screening, interview, and intervention plan, and is delivered using multimedia software (The
National Council on Aging, 2014). The Otago Exercise Program is a home-based, individually
prescribed single-factor fall prevention program for frail adults, facilitated by physical therapists.
It focuses on exercise to increase strength, balance, and endurance. Stay Active and Independent
for Life (SAIL) is primarily an exercise class that is supplemented by fall risk education.
Although it counts as a multifactorial program, SAIL does not address other common risk factors
that are included in Stepping On. Tai Ji Quan: Moving for Better Balance is a single intervention
program that focuses on balance, strength, and physical performance through long-term group
classes in Tai Ji Quan.
As can be discerned, evidenced-based fall prevention programs use a variety of strategies
to address fall risk among older adults. Specific segments of the older adult population may
benefit in different ways from each of these programs. Stepping On, in particular, may be an
ideal fit for older adults seeking a community-based program that addresses various aspects of
fall prevention with the expertise and support of several healthcare professionals and experts.

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Stepping On
Stepping On is an evidence-based multifactorial fall prevention program designed to
increase self-efficacy and modify behaviors in order to reduce falls (Clemson et al., 2004;
Clemson & Swann, 2008). The target population for the program consists of independent older
adults who do not have cognitive impairments and who have either experienced a fall in the
previous 12 months or are concerned about falling (Clemson & Swann, 2008). The course is
structured into seven two-hour sessions followed by a home visit and a follow-up session three
months after the completion of the course. Additionally, a follow-up call is recommended after
six months to check in with participants. Stepping On offers a comprehensive program, covering
factors such as strengthening exercises, fall risks, regular vision screenings, home hazards,
community mobility and safety, medication management, and coping after a fall (Clemson &
Swann, 2008). The program also aims to increase self-efficacy in order for the participants to
take control, assess risk, and make informed decisions that lead to safer behaviors and reduced
incidence of falls (Clemson et al., 2004; Clemson & Swann, 2008). These program outcomes
follow the core principle that increasing self-efficacy can have a positive effect on initiating and
changing health behaviors; however, more research is needed to examine whether this
multifactorial program is an effective way to reduce falls (Bandura, 1995).
Stepping On was tested in a randomized controlled trial using falls as the primary
outcome, with a resulting 31% reduction in falls for the intervention group (Clemson et al.,
2004). This was a clinically meaningful result, indicating that Stepping On is an effective
program for the target population. Secondary outcomes in this study addressed self-efficacy and
the adherence to weekly strength and balance exercises, routine vision examinations, prescribed
medications, and recommendations arising from the home visit. Though self-efficacy was not

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shown to have increased as measured by the Modified Falls Efficacy Scale (MFES), participants
did make use of more protective behavioral practices than did control subjects. After fourteen
months, more than half of the participants (59%) were still doing their weekly exercise routine,
and 72% had initiated a vision assessment. The number of medications did not change for either
group, but the program participants were less likely to start a new psychotropic drug than the
control group. Finally, 70% of the participants adhered to at least half of the home modification
recommendations. Though the secondary outcomes did not show a significant difference
between groups, they did support the idea that behaviors can be changed. Addressing all risk
factors in a multifactorial program such as Stepping On can educate older adults in ways to
change their behavior and decrease their risk of falls.
Systematic reviews of multifactorial programs have demonstrated that they are effective
in reducing falls, but not fall risk (Gillespie et al., 2012). This could be the result of the difficulty
in assessing fall risk. For example, if a client changes a behavior because he or she has been
educated on fall prevention, the corresponding decrease in fall risk can be difficult to measure.
Although there is some indication in the literature that multifactorial interventions are no more
effective for fall prevention than single interventions (Campbell & Robertson, 2007; Day, 2013),
the complexity and variety of interventions addressing multiple risk factors make it difficult to
assess which components within programs are most effective (Campbell & Robertson, 2007;
Day, 2013; Gillespie et al., 2012; Tinetti, 2008). Elements may benefit participants differently
within programs depending on the individual needs.
Finally, by encouraging behavioral changes through its various interventions, Stepping
On empowers participants to establish an exercise routine and take other actions, decreasing their
fear of falling. Among older adults, fear of falling and reduced physical activity are consistently

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associated with falling (Cumming, Salkeld, Thomas, & Szonyi, 2000; Deshpande et al., 2008;
Gagnon & Flint, 2003; Murphy, Williams, & Gill, 2002; Painter et al., 2002; Zijlstra et al.,
2007). Fear of falling is negatively correlated with diminished physical activity (Painter et al.,
2012), which can cause activity limitations, thereby increasing the likelihood of falling (Gagnon
& Flint, 2003). Stepping On promotes exercise and after completion of the program, participants
show an adherence to an exercise routine, supporting an increase in physical activity. This
suggests that participants decrease their fear of falling by increasing their physical activity.
Increasing physical activity by establishing an exercise routine is a major component of
the Stepping On program, however, addressing all risk factors are just as important in decreasing
the risk of falls. The program has several components that focus on different domains of function
for the older adult. The various components bolster the individual’s capabilities by promoting
self-control, increasing independence, and educating participants on actions they can take to
decrease their fall risk.
Components of the Stepping On program. There are various risk factors linked to falls
among older adults. These include decreased lower body strength and balance, side effects from
medication, changes in vision, and other environmental and behavioral factors (National Center
for Injury Prevention and Control, 2008). Stepping On addresses each of these factors, beginning
with the use of exercise and education to build balance and strength.
Exercise. Exercise participation is an effective method for preventing falls, and provides
the additional advantage of supporting an individual’s overall health (Gillespie et al., 2009;
Sherrington, Tiedemann, Fairhall, Close, & Lord, 2011; Silva, Eslick, & Duque, 2013). For the
older adult, regular exercise can positively impact blood pressure, diabetes, osteoarthritis,
osteoporosis, the lipid profile, and neurocognitive function, and is associated with reduced

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mortality and age-related morbidity (Nied & Franklin, 2002, p. 419). Exercise can also improve
functional capacity and increase self-efficacy (Brassington, Atienza, Perczek, DiLorenzo, &
King, 2002; Cress et al., 1998), thereby assisting older adults to live more active and independent
lives.
The exercise component of Stepping On is modeled on current best practices in fall
prevention, which indicate that exercise interventions targeting fall risk must address balance and
at least one other area of musculoskeletal performance, such as strength, flexibility, or endurance
(Gillespie et al., 2009; Sherrington et al., 2011). The degree to which participants engage in
exercise is also important, as it directly correlates with the protective benefits associated with
exercise (Sherrington et al., 2011; Silva et al., 2013). Two strategies that support engagement in
exercise are the supplementation of group-based exercise with home-based exercise and the
fostering of ongoing engagement in exercise (Gillespie et al., 2009; Sherrington et al., 2011).
Stepping On successfully incorporates all of these factors by addressing lower body strength and
balance, providing exercise opportunities for peer group participation, conducting follow-up
interventions through home visits and a follow-up session, and encouraging participants to
adhere to an exercise program in the long-term.
Vitamin D and calcium. Stepping On provides further support for musculoskeletal
performance by educating participants on the importance of vitamin D and calcium for optimal
function. In the musculoskeletal system, calcium is essential for bone strength and repair as well
as muscular function, while vitamin D is necessary for calcium uptake. Declining calcium and
vitamin D levels in the elderly have been linked to osteoporosis and bone loss, which can lead to
falls (Bischoff et al., 2003). Low serum concentrations of vitamin D have also been linked to
balance problems, impaired lower extremity function, low bone mineral density and muscle

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weakness (as cited in American Geriatrics Society Workgroup, 2014). Proper levels of both
vitamin D and calcium are equally important in preventing falls (Bischoff et al., 2003). Stepping
On participants are educated on these facts and are informed of different options for obtaining
these nutrients, including food sources, nutritional supplements, and exposure to sunlight (for
vitamin D). Not only does Stepping On provide education on the benefits of supplements, the
program also educates participants regarding medication management.
Medication management. Due to the link between certain medications and falls among
older adults (Moylan & Binder, 2006), medication management is an important factor to address
in fall prevention. The American Geriatric Society Beers Criteria (2012) identifies certain
medications as inappropriate for older adults due to potential adverse effects. For example,
benzodiazepines can cause cognitive impairment and delirium, increasing the risk of falls in
older adults. Some medications listed on the Beers Criteria are still prescribed for this
population, either because of lack of knowledge about their effects on balance in older adults, or
because of specific medical conditions requiring the medication.
The older adult population tends to be more sensitive to some medications, particularly
those on the Beers Criteria (2012), due to their decreased metabolism of long acting agents.
Stepping On addresses this risk factor by inviting a local pharmacist to educate older adults on
medication management. Participants are informed of preventive strategies, such as interacting
regularly with pharmacists and doctors to ask questions about drug interactions, gaining
awareness of their side effects, and keeping a personal medication card with a list of up-to-date
prescriptions.
Vision care. Stepping On also educates participants regarding the impact that vision has
on fall risk and prevention. Vision impairment and loss advance rapidly with age (Centers for

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Disease Control and Prevention, 2011). These vision changes adversely affect postural stability
and increase the risk of falls among the elderly (Lord, Menz & Sherrington, 2006). Vision
challenges are especially troublesome, as older adults are often unaware of their visual decline,
and those who have low vision are more likely to fall (Jack, Smith, Neoh, Lye, & McGalliard,
1995; Lord et al., 2006). Educating participants on factors such as the importance of appropriate
eyeglass prescriptions and regular eye examinations can decrease opportunities for vision related
falls.
Home modification and safety. Many falls experienced by older adults occur in the home
or surrounding area due to environmental hazards (Lord et al., 2006). The interaction between a
person’s physical abilities and his or her environment is important in determining fall risk.
Stepping On incorporates the use of problem solving strategies and reflection to educate clients
on the importance of home modification and safety. The program also addresses home safety by
providing a home visit by an occupational therapist. This visit includes screening for hazards
such as poor lighting, stairways, rugs, slippery surfaces in the bathroom, and electrical cords in
walkways. Participants are informed about how these hazards can cause falls and are provided
suggestions for implementing home modifications.
Although addressing environmental hazards is important, the research is inconclusive
regarding the impact of home modification in preventing falls. A Cochrane Review of twenty-
nine randomized trials in which fall injury was an outcome concluded that there was a lack of
evidence demonstrating that home modification reduced the risk of falls (Turner et al., 2011).
However, because many of the studies included multiple and varied interventions, it was difficult
to isolate the role that home modification played.

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Community mobility and outdoor safety. To address falls outside the home, Stepping On
educates participants on outdoor safety and community mobility. Approximately half of falls
experienced by older adults occur outdoors (Nyman, Ballinger, Phillips, & Newton, 2013).
Certain outdoor behaviors lead to falls, including rushing to get to places, not attending to the
route ahead, lack of familiarity, not using a cane or walker appropriately, and lacking confidence
(Clemson, Manor, & Fitzgerald, 2003; Nyman et al., 2013). Stepping On incorporates these
findings by inviting a community safety expert to educate participants on road rules and
pedestrian issues in their community. This expert suggests strategies such as scanning for
hazards, safely negotiating curbs and ramps, and slowing one’s pace. In line with World Health
Organization guidelines (2007) for best practices, the participants also set goals for practicing
what they have learned in community settings. By addressing fall safety in community settings,
Stepping On enables participants to engage in a wider variety of meaningful occupations with
confidence in their ability to be safe.
Stepping On, occupational therapy, and MOHO. Living with increased fear and risk of
falling can be challenging for many older adults, particularly for those who have experienced a
fall and sustained injuries in the past (Cumming et al., 2000). This often leads to decreased
participation in occupations or occupational deprivation (Boye et al., 2013. By addressing
multiple factors complicit in the etiology of falls, Stepping On supports the self-efficacy of
participants, which can lead to improved engagement in meaningful occupations.
As a holistic health intervention, Stepping On fits well within the scope of the
Occupational Therapy Practice Framework (American Occupational Therapy Association
[AOTA], 2014) and the nature of occupational therapy as a client-centered practice. The
components of Stepping On address several areas within the domain of occupational therapy.

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The occupations addressed in the program are classified as instrumental activities of daily living
by the framework and include physical fitness, health management, and safety awareness. To
support these occupations, Stepping On focuses on client factors such as vision, balance, and
muscle strength; performance skills including motor and process skills; performance patterns
such as habits and routines; and contextual and environmental factors.
By addressing the interrelated internal and external factors that contribute to self-efficacy
and occupational participation, Stepping On aligns well with the Model of Human Occupation
(MOHO), which proposes that humans are characterized by three related concepts: volition,
habituation, and performance capacity (Kielhofner, 2002). The motivation to engage in
occupation is an aspect of volition, which arises from one’s values, interests, and estimation of
one’s abilities. Stepping On’s goal of increasing awareness of one’s capacity to reduce fall risk
can be understood under this view of volition. Additionally, volition drives the very participation
in Stepping On as the participants enroll and participate voluntarily. Habituation involves the
development of routines, such as those occupations performed on a regular basis, without having
to devote much thought to the decision to do them as they are done automatically. Stepping On
relies on habituation by promoting the establishment of new protective habits that may reduce
fall risk. Finally, MOHO proposes that performance capacity is dependent upon body structures
and functions required to engage in particular occupational behaviors. As they relate to fall
prevention, these include muscles for standing and walking, visual acuity to navigate safely in
the environment, and vestibular sensory organs to maintain balance. Stepping On addresses all of
these systems by acknowledging the effects of age on the body and the potential to improve
function in these systems when possible.

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Age-related changes put older adults at higher risk of falling, which can lead to reduced
function and participation in daily occupations. Stepping On falls within the domain of
occupational therapy and fits well in practice settings that serve older adults. Implemented in
accordance with the principles of the MOHO, Stepping On can be an effective intervention that
enables and enhances occupational performance among older adults who are at risk of
occupational deprivation due to fall risk or reduced self-efficacy.
Conclusion
Falls resulting in TBI, hip fracture, and other types of injury can significantly impact
occupational participation among the older adult population. Even in the absence of a fall, the
loss of self-efficacy that can occur when one has a fear or risk of falling can limit an older adult’s
participation in meaningful and necessary occupations. Stepping On is an evidence-based
multifactorial falls prevention program that aims to address this source of occupational
deprivation by reducing the risk of falling and increasing self-efficacy among its participants.
The program can be effective for a wide variety of individuals as it includes components which
address balance, strength, musculoskeletal health, medication management, vision care, home
modification and safety, community mobility, and outdoor safety.
As a fall prevention program, Stepping On falls within the domain of occupational
therapy by acknowledging the complex relationship between the individual, the environment,
and occupational demands. Although this program addresses important risk factors and complex
relationships, the question remains: are multifactorial programs the most effective means of
promoting fall prevention? Further research is needed to answer this question.

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Chapter III: Methods
The present program evaluation utilized a retrospective approach, analyzing data from
Stepping On sessions completed between September of 2013 and March of 2015. The program
evaluation was conducted through secondary analysis of the archived data from these classes.
The research design examined the results from existent pre- and post-surveys and the pre- and
post-standardized Sit-to-Stand Test that are part of Stepping On program implementation. There
are four outcomes measured: self-efficacy, lower body strength, reduction of risk factors and
perceived value. The methods selected take into account the available data that was collected
during the program. A quantitative and qualitative analysis allowed the researchers to examine
both the impact and the value of the program for the participants.
Participants
Stepping On is a component of Stanford Health Care’s Community Outreach and Injury
Prevention Program. Classes are held several times per year and group sizes are kept relatively
small (nine to 15 participants) to facilitate an optimal environment for learning and sharing
experiences. Participants in Stepping On were recruited via flyers and newsletters at community
centers for older adults, physicians’ offices, and area organizations working with older adults.
Based on Stepping On guidelines, the inclusion criteria for program participation mandate that
participants must be age 60 years or older; they must reside in the community; they must be able
to attend program classes and participate in the exercises; they must have an interest in the
program; and they must be able to walk into the classroom. Exclusion criteria required
participants to be free of any major cognitive impairments or health issues.

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Materials and Instruments
Two types of instruments were utilized to examine the research question: program
surveys and the 30-second Sit-to-Stand Test. The Stepping On program and corresponding
assessment tools were originally developed by Dr. Lindy Clemson at the University of Sydney,
Australia (Wisconsin Institute for Healthy Aging [WIHA], 2013). WIHA, with the support of the
CDC, developed an American version of the program that was tested and demonstrated
comparable results. WIHA was granted permission to utilize the original program manual and
surveys for Stepping On in the U.S. The surveys in this study deviated slightly from these
originals. Staff at the University of California, Davis Medical Center and at Stanford Health Care
modified them to include relevant questions found in another multifactorial community-based
falls prevention program, A Matter of Balance (Ellen Corman, e-mail communication, February
23, 2015).
The surveys provided both quantitative and qualitative data for assessing the results of
the program. The pre-survey recorded baseline data and provided demographic information of
program participants. The post-survey demonstrated changes in behaviors and beliefs achieved
through the program. Responses to questions, open-ended comments and Likert items were used
to determine self-efficacy, fall risk factors, and perceived value of the program. Among these
questions, the response categories include Likert scale questions, dichotomous questions, and
open-ended format questions. Questions pertaining to perceived value of the program were only
asked in the post-test questionnaire. An optional comments/suggestions box was included in the
post-survey.
Stepping On employs the 30-second Sit-to Stand Assessment (Bohannon, 1995) to track
changes in lower extremity strength and dynamic balance for older adults. In this test, the

19
required equipment includes a chair without armrests and a stopwatch. The objective is for the
individual to move from a sitting position to a standing position as many times as possible in 30
seconds. The individual must arrive at a full standing position every time and have the ability to
change positions without using arms for support or stability.
The 30-second Sit-to-Stand test provides quantitative data on participants’ leg strength
and endurance (Bohannon, 1995). A high risk of falls may be indicated for individuals who score
below the average amount of sit to stands in their age and gender group. The Sit-to-Stand
assessment holds both reliability and validity (including construct validity and criterion validity).
Test-retest intraclass correlations of 0.84 for men and 0.92 for women indicate good reliability
(Jones, Rikli, & Beam, 1999). It is also utilized to track functional lower body strength in similar
fall prevention programs such as A Matter of Balance (Lau, Reyes, Angeles, & Hollaway, 2015).
In that program, the assessment was used to measure participants’ physical fitness level at the
beginning and end of the program. Additionally, the 30-second Sit-to-Stand test is commonly
used to assess physical function for older adults with hip and knee osteoarthritis (Dobson et al.,
2013).
Program Evaluation Data Collection
Program facilitators administered the surveys and Sit-to-Stand test. Stepping On
facilitators received instruction on these assessments and their appropriate implementation
during program training. Facilitators explained the purpose of the questionnaires and the Sit-to-
Stand evaluation to participants at the introductory class session. The participants were then
asked to complete surveys and the Sit-to-Stand test at the first (pre-) and last (post-) Stepping On
session.

20
Once the program data was collected, only the program director, Stepping On instructor,
and administrative assistant had access to it. The data was entered into a database by the
instructor (primarily) and administrative assistant. A number was assigned to each participant,
and the relevant responses and measures from the instruments were transferred into a spreadsheet
with no identifying information (e.g. names and addresses). All identifying data was stored at
Stanford Health Care and was not available to student investigators. The authors only had access
to the redacted data in this spreadsheet.
Data Analysis
The data analysis involved both quantitative and qualitative methods. An analysis that
combines quantitative and qualitative methodologies can provide a more thorough understanding
of program results (Steckler, McLeroy, Goodman, Bird, & McCormick, 1992). There were four
areas of data analysis, each pertaining to different sections of the research question. The
independent variable or intervention was participation in the Stepping On program for a
minimum of five sessions. The dependent variables or outcomes that were examined include:
changes in self-efficacy, changes in lower extremity strength, reduction of fall risk, and
perceived value of the program. The data sources will include the pre- and post- surveys and pre-
and post- results from the 30-second Sit-to-Stand Test.
Changes in self-efficacy were assessed by responses to the statement: “There are actions I
can take to reduce my risk of falling,” included in the pre- and post-surveys. The five-point
Likert scale response items for this statement include: Strongly Agree, Agree, Neutral, Disagree,
and Strongly Disagree. Likert scale items may be combined into a single composite variable
during the data analysis process to provide a quantitative measure of change (Boone and Boone,

21
2012). The items were analyzed as five interval data points and compared through a Wilcoxan
singed-rank test.
Comparisons of 30-second Sit-to-Stand test results taken at the beginning and end of the
seven week course assessed improvements in lower body strength. Numerical data was
compared using a paired t-test. Individual 30-second Sit-to-Stand results were compared to
normed data by age and gender to ascertain the percentage of participants performing at average
level or above at the time of the pre- and post-test.
Reduction of fall risk, including the use of vision assessments, medication reviews, and
environmental modifications, were ascertained through descriptive data gathered from the post-
surveys. The descriptive data reported changes participants made as a result of the program. In
addition, open comments were coded and information relevant to modification of risk factors
was identified. Any major themes emerging related to risk factors were reported in a qualitative
data analysis.
To understand the perceived value of the program, the researchers reviewed attendance
records and relevant responses to the statement “I would recommend this class to a friend or
relative” in the post-survey. The available five-point Likert scale response items for this
statement include: Strongly Agree, Agree, Neutral, Disagree, and Strongly Disagree.

22
Chapter IV: Results
Participants
Descriptive analysis was applied to the baseline sample population of 64 individuals who
enrolled in Stepping On. Ten of these participants were excluded from the final data analysis
because they attended fewer than five classes, and data was incomplete for some participants, as
noted in the results. Age, gender, race, one-year fall history, use of a walking aid (such as a cane
or walker), prescription medication usage, and receipt of help at home were analyzed.
The age, gender, and race of participants are described in Table 1. Twelve-month fall
history was compared with these characteristics and with rates of walking aid usage, prescription
medication usage, and receipt of help at home. Among 61 participants who reported their fall
history (see Table 2), 54% reported having fallen at least once in the prior year (n = 33). The rate
of falls between males and females is similar, with 53% of females reporting a fall (n = 23),
compared to 56% of the males (n = 10). The high proportion of Caucasian participants limited
the information that could be gained from analyzing falls according to race. Individuals who
used a walking aid and who received help at home were more likely to experience a fall than
those who did not. Prescription medications were used by 90% of the participants and this does
not appear to be related to fall history.
Table 1
Demographics of Participants
Age Gender, n (%) Race, n (%)
Min 62 Female, 46 (71.9) Asian, 8 (12.50)
Max 96 Male, 18 (28.1) Caucasian, 52 (81.25)
Mean 81.37 ± 7.77 Other, 4 (6.25)

23
Table 2
Fall History and Fall-Related Medical Care
Fall, past 12 months, n (%) Fall, past 3 months, n (%) Fall requiring medical care, n (%)
Yes, 33 (54.1) Yes, 16 (26.2) Yes, 15 (24.6)
No, 28 (45.9) No, 45 (73.8) No, 46 (75.4)
Table 3
Fall History and Use of Walking Aids, Help at Home, and Medications
Fall History Use walking aid, n (%) Receive help at home, n (%) Use 5+ medications*, n (%)
Fall (past 12 mos.)
(n = 33) 12 (92.3) 23 (67.6) 7 (58.3)
No fall (past 12 mos.) 1 (7.7) 11 (32.4) 5 (41.7)
(n = 28)
_____________________________________________________________________________
Note. This table represents fall history among participants who reported using a walking aid (n
= 13), receiving help at home (n = 34), and using 5 or more medications (n = 12).
*Use of 5 or more medications is considered a fall risk factor in nursing home populations
(Hartikainen, Lönnroos, Louhivuori, 2007)
Outcomes
Self-efficacy. Self-efficacy of program participants was assessed through the statement “I
can take actions to reduce my risk of falling” in the pre- and post-surveys. Initial analysis of
available responses demonstrated that the results were not normally distributed, with the
responses skewed toward positive positions on the Likert scale in both the pre- and post-test.
Because of this, a paired t-test could not be employed to analyze the data. Instead, a Wilcoxon
signed-rank sum test was utilized to compare the changes in responses within the group. Of the
participants who provided answers in both the pre- and post-surveys (n = 38), 26 demonstrated
no change in Likert scale rank, nine increased rank and three decreased rank. Although the
overall mean score increased positively on the Likert scale from the pre-test (M = 4.50, SD =

24
0.56) to the post-test (M = 4.68, SD = 0.47), the changes in responses were not deemed
significant (Z = -1.807, p = 0.07).
Participant valuation. Participant valuation of the class was assessed through class
attendance and by responses to the statement “I would recommend this class to a friend or
relative” in the post survey. A total of 65 participants registered in five Stepping On courses
from September 2013 to November 2014. There were three dropouts due to health and other
personal reasons. Of the 62 remaining, 87% (n = 54) completed at least five of the seven
Stepping On classes.
Participants were asked to respond to the statement “I would recommend this class to a
friend or relative.” All 51 of the participants who responded stated they would recommend the
course (78% strongly agreed and 22% agreed).
Lower body strength. The 30-second Sit-to-Stand test was administered to participants
during the first and last session of the program in order to assess lower extremity strength. The
test provided a standardized measure for changes in strength and norms by age and gender for
performance in older adults. The data resulting from the test was a numeric count, which meant
ratio or parametric data.
The Sit-to-Stand data was complete for 44 participants. The average scores of the post-
test were greater than the pre-test (see Table 4). In order to analyze whether the program
accounted for an increase in the scores on the post-test, a paired t-test was used to determine if
the differences were significant. Results demonstrated an average increase from the pre-test (M =
9.68, SD = 3.71) to post-test scores of (M = 10.57, SD = 3.22). The two-tailed t-test indicated that
participants’ lower body strength increased after participation in the program (t(43) = -2.12, p =

25
0.04). Participants performing at average or above for their age and gender group increased from
59% to 76%.
Table 4
Paired Samples t-Test for Sit-to-Stand Test
Pre-test STS Post-test STS
Mean 9.681818 10.56818
Variance 13.75687 10.39059
Observations 44 44
df 43
t Stat -2.120956
P(T<=t) two-tail 0.039731
Note: STS stands for Sit-to-Stand Test
Reduction of fall risk. This analysis includes those participants who attended at least
five classes, including the final (seventh) class, and completed the post–survey. To analyze the
outcome of fall risk, the post-survey included the following statement: “As a result of this class,
please tell us whether you’ve taken action with medications, environment, vision, behavior or
other actions.” There were options for hard-coded and open-ended responses possible for this
item.
Table 5
Participant Reported Changes to Reduce Fall Risk
Response Category Responses (n = 35)
I plan to talk to my doctor about medications. 6 (17%)
I have made changes to my environment. 6 (17%)
I plan to continue exercising. 24 (69%)
I have made changes in two areas. 12 (34%)
I haven’t made any changes. 2 (6%)
Of the 54 participants meeting the inclusion criteria, 35 (65%) completed the post-survey,
and of these, 24 (69%) answered that they have taken action or plan to take action in changing

26
their behavior in a specific way to decrease their fall risk. Table 5 demonstrates participants’
reports of changes they planned to make in each category to decrease fall risk. Five of the 35
participants responded in the open comments section. Participants shared they have made or plan
to make changes in reducing their risk of falls in the following areas: having a greater awareness
of surroundings, walking more slowly, exercising, making changes in their environment, and
planning on getting a vision check.

27
Chapter V: Discussion
This chapter discusses the results in terms of implications for this and other fall
prevention programs, recommendations for further research, and recommendations for modified
recruitment and assessment strategies. To assess the effectiveness of the Stepping On program,
an analysis was done on four outcomes that included self-efficacy, perceived value, strength, and
fall risk. The results demonstrated that there was a positive perceived value of the class, a
significant increase in strength and a decrease in fall risk. There was no significant change in
self-efficacy. The results suggest that Stepping On is an effective multi-factorial program in fall
prevention, given that three of the four outcomes had a positive change. However, program
improvements could be made in these areas: outcome measurements, follow-through with
participants, and the expansion of the population being served.
Participants
A majority of program participants were Caucasian (81%) and female (72%). The
population of Palo Alto, California, where the program took place, is 64.2% Caucasian, 27.1%
Asian, 6.2% Hispanic or Latino, and 1.9% Black or African American (United States Census
Bureau, 2010). 51.1% of residents are female, and 48.9% are male. Greater efforts to recruit
male and non-Caucasian older adults could be beneficial to those members of the community
who are currently under-represented among program participants. Such efforts could include
posting flyers in public places where non-Caucasian residents are likely to convene (grocery
stores, churches, parks) and encouraging female participants to recruit male relatives and friends.
Analysis of the data was limited in regards to fall history due to participants not being
provided with a clear definition of what constitutes a fall. Participants may have only considered
those falls which resulted in an injury or which required medical care, rather than falls, which did

28
not have serious consequences. Providing a clear definition of this term to clients prior to
obtaining their fall history would result in a more accurate assessment of participant fall history.
Outcomes
Self-efficacy. One of the main goals of the Stepping On program is to improve the self-
efficacy of participants as it relates to falls and fall prevention (Clemson et al., 2004). It is likely
that this evaluation demonstrated no significant change in self-efficacy because, by registering
and participating in a falls-reduction class, the participants already demonstrated a high degree of
self-efficacy. Participant responses support this as they were skewed towards the positive on the
Likert scale in the pre-survey.
Another possible reason for the lack of change in self-efficacy may be related to the small
amount of data collected pertaining to this outcome. There was only one item (measured in the
pre- and post-surveys) related to this goal. This may not be sufficient to truly understand how
participants view their own capacities, their understanding of what changes can be made, and if
they have the power to effect these changes. Since increasing self-efficacy is a goal of the
program, participant surveys could be expanded to include more items related to self-efficacy.
Another option may be to administer an existent falls self-efficacy assessment, such as the
Modified Falls Self-Efficacy Scale or the Mobility Efficacy Scale, to participants at pre- and
post-testing.
Program administrators may also consider that, if in fact the program mainly attracts
participants that already exhibit a high degree of self-efficacy; populations with low degrees of
self-efficacy are not being effectively reached or recruited. This population may have a higher
degree of challenges (such as age-related disabilities) and may not be aware of or understand the

29
benefits of the program. It is recommended that this be taken into consideration when
recruitment strategies are being planned and implemented.
Valuation. Consistent attendance and 100% positive post-survey responses on the
valuation statement demonstrated that participants valued the program. Because Stepping On is a
community-based program spanning almost two months in length, attendance can be challenging
for participants due to a variety of factors, including illness, community mobility factors, and
other existent personal commitments. Attendance of at least five classes (equivalent to 71%
adherence) was considered “full participation” by the program administrators. As 87% of
participants were able to meet this standard, the program effectively engaged participants.
The post-survey valuation item was 100% positive. However, it was also limited to one
statement with Likert scale responses. The program might benefit from more extensive feedback
from participants on this subject. There was an open comments section in the port-survey that
may have provided more insight into participant valuation of the program. This data was not
available to evaluators and may not have had enough responses to provide further understanding.
Lower Body Strength. The analysis revealed a statistically significant increase in Sit-to-
Stand test scores from pre- to post- among Stepping On participants. Because the 30-second Sit-
to-Stand test is commonly used to measure leg strength and holds high reliability and validity,
the positive change in scores indicates an increase in functional lower body strength among
participants after the program. This increase may also be clinically significant, given that the
scores increased through the short duration of the program.
Overall, the results demonstrate that Stepping On increases lower body strength among
participants. However, the multifactorial nature of the program makes it challenging to conclude
that exercising alone led to increased strength; the results could be due to other aspects of the

30
program. Additionally, the study would have benefited from having a larger sample size for the
Sit-to-Stand assessment.
Reduction of fall risk. Participants were asked whether they had made changes to reduce
their risk of falls by making changes in the areas of medication, environment, vision, behavior or
other action. Of those that answered this question (n=35), 69% agreed that they plan to continue
exercising, and approximately one-third planned on making two changes. The fact that
participants plan to continue exercising is significant, as this is an effective method for
preventing falls (Gillespie et al., 2009; Sherrington, Tiedemann, Fairhall, Close, & Lord, 2011;
Silva, Eslick, & Duque, 2013).
Since exercise was chosen most often in the post-survey, it supports the concept that
carry through of an exercise routine is essential for making a change in daily habits. Stepping On
classes promote exercise during each class and ask participants to keep an exercise log, so that
they can make exercise a routine in their lives. This protocol is an effective short-term way to
decrease the risk of falls in the older adult population. To have a greater long-term impact as a
program, there needs to be consistent follow-through with the participants at three, six, and
twelve months to see if they are still adhering to their exercise program, following through with
medication management, and practicing environmental awareness. The program does offer a
booster session at three months; however, it was difficult to secure participant’s attendance at the
follow-up session. It would be helpful to analyze the best way to support participants after
completion of the classes to maintain the benefits of the program.
Conclusion
The results of this program evaluation indicate that Stepping On is an effective
multifactorial fall prevention program. There are improvements to be made in the area of

31
outcome measurements, participant follow-through, and reaching populations that would benefit
from this program. Currently, more research is needed to demonstrate that multifactorial
programs are effective in fall prevention in the older adult population. Also, a comparison of fall
prevention programs that includes a cost analysis and a study of which components are the most
effective at reducing falls would be very beneficial. Studies of higher quality, using standardized
assessments with a control group, would strengthen the quality of research and the results of
future program evaluations.

32
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