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RAPID COMMUNICATION |
1 Hornsby Ku-ring-gai Hospital, Sydney, New South Wales, Australia.
2 Rehabilitation Studies Unit, Faculty of Medicine, University of Sydney, Australia.
3 School of Public Health, University of Sydney, Australia.
Address correspondence to Susan E. Kurrle, MB BS, PhD, Rehabilitation & Aged Care Service, Hornsby Ku-ring-gai Hospital, Palmerston Rd., Hornsby, NSW 2077, Australia. E-mail: kurrle{at}bigpond.com
Abstract
Background. Hip protectors can prevent many hip fractures in older persons at high risk for falling. Few published studies have investigated the use of hip protectors in community-dwelling older persons, and the level of adherence with their use, and predictors of adherence in this setting, are not clear. The aim of this study was to report the predictors of adherence and the level of adherence with the use of hip protectors in frail community-dwelling older women.
Methods. This cohort study of the intervention group of a randomized, controlled trial recruited participants from aged care health services in urban areas of northern Sydney, Australia. Participants were 302 women who were 74 years or older (mean age, 83 years) and who had 2 or more falls or 1 fall requiring hospital admission in the previous year and who lived in their own homes. The main outcome measure was adherence with the use of hip protectors.
Results. Adherence was approximately 53% during the 2 years of the study, and hip protectors were worn at the time of 51% of falls. The significant independent predictors of nonadherence with hip protector use were lower self-efficacy for hip protector use (odds ratio [OR], 0.51; 95% confidence interval [CI],.33 to.79), higher number of perceived barriers to hip protector use (OR, 0.52; 95% CI,.38 to.72), and lower self-rated health (OR, 0.71; 95% CI,.55 to.93).
Conclusions. Three easily measured factors independently predicted subsequent adherence with hip protector use. These findings may form the basis for strategies to improve adherence with the use of hip protectors and with other types of treatment or preventive strategies in older persons.
We report the results of a study of adherence with the use of hip protectors to prevent hip fracture, in which demographic and health-related information and the health beliefs and self-efficacy of participants were evaluated to determine their effect on adherence. Hip protectors are shields or pads that are held in place over the hips and decrease the force of a fall onto the hip. Several studies have shown that hip protectors are effective in preventing most hip fractures when worn as recommended (3–5), and adherence with their use has been identified as a crucial issue (6,7).
METHODS
The design and methods of this randomized, controlled trial have been reported elsewhere (8,9). Briefly, our aim in this 2-year study was to establish the effectiveness of hip protectors in preventing hip fracture in 600 community-dwelling older women who were at high risk for hip fracture. Participants were randomly allocated to intervention (use of hip protectors) or control groups. Demographic and health-related data were collected at baseline, and information on falls and hip and other fractures was collected at regular intervals during the study. Questions assessing possible predictors of adherence were developed for the study using the Health Belief Model (beliefs about disease risk and consequences, and possible barriers to treatment) (10) and the self-efficacy component of Social Cognitive Theory (confidence in ability to undertake a certain treatment) (11). These were administered to the 302 participants in the intervention group after randomization. Participants were asked to wear the hip protectors all their waking hours, and full adherence was defined as wearing hip protectors from the time of arising in the morning to going to bed at night. Adherence was measured 5 times during the 2-year study and was reported as a percentage of the total possible wearing time.
Descriptive statistics summarizing adherence were calculated, and the associations between adherence-, demographic-, and health-related variables, and adherence question responses, were evaluated using Mann-Whitney U tests and Kruskal Wallis tests as appropriate. Significance testing was two-tailed, with p <.01 accepted as significant because of the large number of comparisons. A logistic regression analysis was performed to examine the independent predictors of adherence.
RESULTS
Table 1 shows selected baseline characteristics of the participants who used hip protectors. Their mean age was 83 years, 25% of them had sustained a previous hip fracture, and 58% had a history of some other fracture. Thirty-three participants (11% of the group) died during the 2-year study period.
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No association was found between the level of adherence and the demographic variables of age, marital status, level of education, income source, and occupational status, or the health-related variables of functional status at study commencement, cognitive status, history of hip fracture, history of falls, or fear of falling. A significant association was found between self-rated health at study commencement and subsequent adherence, with participants who reported their health as excellent, very good, or good having a higher level of adherence than participants who reported their health as fair or poor (p =.003).
There was a strong association between self-efficacy for wearing hip protectors and subsequent adherence, with high self-efficacy predicting high adherence (p =.000). There was a strong association between perceived barriers to wearing hip protectors and subsequent adherence, with the reporting of one or more perceived barriers being associated with lower adherence (p =.000).
In a logistic regression analysis to examine factors predicting adherence, perceived barriers, self-efficacy, and self-rated health were independent predictors of subsequent adherence with hip protector use (Table 3). The variables were coded negatively (i.e., more perceived barriers, lower self-efficacy, and poorer self-rated health were associated with lower subsequent adherence).
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DISCUSSION
By the end of the 2-year study, only 51% of participants were wearing their hip protectors for more than one half of their waking hours. This level of adherence is consistent with the often-quoted level of 50% (15), which is the percentage of patients with chronic disease complying with their physicians' recommendations, regardless of disease, type of treatment, or age. With a relative risk of.2 for sustaining a hip fracture while wearing hip protectors compared with not wearing them, the importance of high levels of adherence with hip protectors is clear.
Three factors independently predicted adherence with the use of hip protectors during a 2-year period. Low self-efficacy for wearing hip protectors, 1 or more perceived barriers to the wearing of hip protectors, and fair to poor self-rated health were all independent predictors of low adherence or nonadherence with the use of hip protectors. These factors were assessed at the beginning of treatment using three simple questions.
These findings are consistent with those in the published literature and augment our knowledge in the complex area of adherence. Perceptions of self-efficacy are important in changing current health behaviors, and in initiating new behaviors, and a high degree of self-efficacy is likely to be associated with a high degree of adherence (11). High self-efficacy has been linked to high adherence with exercise programs, dietary regimens, and long-term treatment in several chronic diseases (16). Fair to poor self-rated health was the strongest predictor of medication discontinuation in a large fracture-prevention study (17). The factor of perceived barriers to treatment has been consistently shown to be the component of the Health Belief Model that most strongly predicts health behavior change (18).
The strengths of our study lie in its prospective nature, with assessment of several possible predictors of adherence at baseline, followed by regular measurement of adherence throughout the study. The population studied is representative of frail older women living in their own homes, and none of the 302 participants was lost to follow-up.
This study has important implications for adherence with prescribed treatment. It suggests that future adherence with the use of a recommended treatment, whether medication, use of appropriate assistive devices, exercise, or dietary regimens, can be assessed at the beginning of treatment. Adherence-improving interventions can then be implemented whenever adherence is likely to be less than optimal. Interventions that have been shown to improve adherence include behavioral skill training, self-monitoring, external monitoring/support through telephone or mail contact, and education to enhance self-efficacy (19–22). Strategies to overcome perceived barriers to undertaking treatment could also be included in an education program.
The reporting of fair or poor self-rated health is also an important predictor of adherence, and persons who report fair or poor self-rated health may benefit from further assessment and management of the disability or illness behind the report of low adherence.
The next step is a randomized, controlled trial that assesses predicted adherence at the beginning of a course of treatment, with the objective of using adherence-improving strategies in those patients who are identified as needing assistance to maintain an appropriate level of adherence. Subsequent levels of adherence would be the outcome. This assessment and management of adherence potential will allow a more informed approach to the issue of adherence with prescribed treatment.
Acknowledgments
The authors thank Keri Lockwood, Carol Birks, Jenny Venman, Wendy Burnside, Robert Cumming, and Glenn Salkeld for their assistance.
Supported by a grant from the Australian National Health and Medical Research Council.
Received September 19, 2003
Accepted October 22, 2003
References
This article has been cited by other articles:
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  R. Cardarelli, S. Weis, E. Adams, D. Radaford, I. Vecino, G. Munguia, K. L. Johnson, and K. G. Fulda General Health Status and Adherence to Antiretroviral Therapy J Int Assoc Physicians AIDS Care (Chic Ill), June 1, 2008; 7(3): 123 - 129. [Abstract] [PDF]
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 M. J Parker, W. J Gillespie, and L. D Gillespie Effectiveness of hip protectors for preventing hip fractures in elderly people: systematic review BMJ, March 11, 2006; 332(7541): 571 - 574. [Abstract] [Full Text] [PDF]
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