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The construction of the risks of falling in older people: lay and professional perspectives

Summary

2. Research design

The study had three distinct, but linked phases. The first phase was a review of the literature in relation to older people and considered: research methodologies, falls, health promotion, and risk.

The literature review informed the data collection stages: including the definition of samples and recruitment to the study, the methods to be used, the content of interview schedules, and the analysis and interpretation of data.

The second stage of the study involved data collection with older people and professionals. The approach to data gathering was informed by the material which emerged from the literature review, and included personal in-depth interviews and group interviews. The aim of this exploratory stage was to elicit, from lay elders and professionals, general constructions of falls and the risk of falling in relation to the definition, attribution and prevention of falls. The approaches to lay elders were via established groups and organisations working with older people and also informally using snowball techniques. Professionals were identified in a number of ways via health service, local authority, and voluntary sector organisations and also through informal contacts.

The third and final element of the study aimed to validate and further explore constructions which had emerged from the exploratory interviews, and utilised focus group discussions with older people. Data, in the form of exemplar quotes, derived directly from the earlier data gathering were use as the foci for discussion.

3. Literature review

A review of the literature was conducted in relation to: research approaches with older people; falls in older people; health promotion with older people; and conceptual and theoretical understandings of risk.

Research with older people

The literature indicated that older people are generally co-operative, involved and reliable respondents in research, but that certain approaches were likely to be more acceptable and appropriate. In particular:

• Interview studies with elderly respondents place a number of demands on the interviewers, and interviewers require extensive training, including training to cope with long and possibly stressful interviews
• The social skills of the interviewer are crucial – it may be necessary to match gender if sensitive topics are being discussed and rapport must be established early in the process
• The salience of the topic will affect how involved the elderly person feels in the interview situation
• Interviews should not be over-complex and should use less structured approaches which allow respondents’ narratives to flow conversationally
• Group approaches should bring together individuals who are as homogeneous as possible
• Recruitment to research is more likely to be acceptable if the topic is seen as salient and if contact is made via an already established group or network.

Falls in older people

Attempts to delineate an epidemiology of falls is hampered by:

• The absence of a standard clinical definition of a "fall",
• A lack of consensus about how different falls should be classified
• Variation in the sources of information about falls, the time-frame and age-groupings on which estimates of falls are based.
• The collective evidence suggests, however, that approximately one-third of older people (aged 60 or more) are likely to experience a "fall" in any one year, but this will vary by age and context:
• Falls at younger ages (under 75) are more often associated with extrinsic or external factors
• Falls among those aged 75+ are more often associated with intrinsic or physical factors linked with ageing.
• A wide range of physical, social and psychological factors associated with falls have been identified:
• Physical or physiological correlates of falling include impaired balance and associated links with medication; poor muscle strength, impaired visual acuity and other physiological factors, especially at older ages (see above).
• Environmental factors – such as uneven pavements, loose carpets and ill-fitting shoes - have also been implicated as a cause of falls and in injuries incurred through falling, especially at younger ages (see above)
• Psychological factors such as lack of confidence, a fear of falling itself, and previous experiences of falls have all been linked to increased risks of falling.
• Reviews of falls prevention strategies based on randomised controlled trials confirm that weight-bearing exercise which improves balance, builds up strength, and strengthens bone density confers modest benefits in terms of preventing further falls and minimising injuries to older people who have already experienced a fall.

Health promotion with older people

With an increasing ageing population, health promotion for older age has clear social and economic relevance. While this is an area of increasing interest and activity, there remains no consensus or clear evidence about what approaches to health promotion are acceptable or effective with older people.

In very general terms, older people’s participation in health programmes declines with increasing age, and is linked to marital status, education and income levels, gender, health status, personal or family history, social integration, and health beliefs.

The key issues, which emerge from the literature, are:

• The need for health promotion efforts that reflect the diversity of older people in relation to health status, belief and attitude, behaviour and culture.
• The need to understand and link personal definitions of health to any health promotion effort.
• Multi-factorial approaches – particularly where the focus is on the "whole person" rather than on a specific dysfunction there appear to be long-term benefits.
• One-off interventions – especially those which focus narrowly on professionally defined risk factors - have not been found to be associated with long-term change or benefits

Understanding risk

There is a dearth of empirical work which has explored perspectives on risk in older age and we have therefore drawn on, among other areas, work with young people - particularly in relation to sexual health. In doing so, we believe that there are important parallels and continuities which make that work relevant for this debate. In particular, we believe this research must be influenced by an understanding of how, at different points in the lifecycle, the balance between risks and dangers on one hand and living a 'normal' life on the other hand, might be perceived in ways which are dependent on the predominant concerns at any one time for different groups.

We suggest that work which focuses attention on young people - who are often defined as 'at risk' but who do not often define themselves as such, may have real relevance for understanding older peoples’ constructions of risk. For example, work with young women in relation to teenage pregnancy suggests that the most common response is of the nature: 'it won’t happen to me I'm not that type'. Bad luck or misfortune is perceived as being linked to character rather than to behaviour: without anticipating the results of the study, we suggest that this is a metaphor for understanding risk construction in older age.

4. Generalised constructions of the risk of falling

Group and individual interviews were conducted with lay elders. These extended narratives suggested that constructions of falling were determined by complex contextual factors.

First, the language of fall was found to be crucial. The linguistic terms used by older people to talk about falls are neither neutral nor value-free, and imply quite specific notions of causality and responsibility. The very similar distinctions drawn by lay and professional respondents denote not merely differences in definition, but also differences in meaning and significance.

Second, those who fall are perceived in negative terms to be old, frail and dependent and, possibly, to have a drink problem. The differential use of language to talk about trips rather than falls serves to distance respondents from the negative connotations of falling.

Third, falls are generally regarded as a future risk and not a current concern, and are mostly not salient at younger ages.

Fourth, the concept of a healthy older age is seen as desirable and achievable via activity, gainful pursuits, and continuing independence.

Fifth, although old age is regarded as a state of mind, the impact of bodily change and limitation dominate individuals’ narratives about old age and is perceived to be factor determining a person’s ability to "feel" young, to remain active and to be independent.

Finally, social and cultural differences in acceptance of the ageing process can influence perceptions of risk, vulnerability and dependence.

5. Implications for health promotion

• The language of falls and of old age is critical. The term "fall" is contentious, has negative connotations and its use is likely to inhibit engagement with any preventive programme.
• Targeting "older people" is also likely to provoke a negative or non-response among people who do not relate to portrayals with which they do not identify.
• The emotive connotations of falls suggests that a simple focus on the issue may be negatively received or, even more likely, not received at all. For the younger elderly, in particular, falls are perceived to be, at most, only a distant future risk.
• The promotion of healthy ageing rather than a healthy old age may be more attractive and accessible to all age groups.
• The issue of falls for most people only becomes salient if the individual has themselves had a ‘bad’ fall, although awareness of health problems such as osteoporosis represents a possible route for discourses about falls prevention.
• Most older people want to be able to live their lives as they had, doing the things they enjoyed, and managing everyday activities for themselves. Independence can be fiercely guarded, and among those who have fallen there is a need for sensitive approaches, which acknowledge individuals’ needs to be, and be seen to be, independent.
• Feeling young was highly valued and was perceived to derive from being independent and having interests. Within that context an emphasis on the promotion of health ageing rather than a healthy old age may be better received at all ages. Finding ways to enhance confidence, social activity and promote independence may be particularly effective in facilitating change among those groups for whom falls and, indeed, old age, are perceived to be merely a distant future risk.

1. Background

Falls are the most common cause of accidental death at home among those aged 75 or more in Scotland: in addition to deaths, falls are associated with considerable physical, psychological and social morbidity.

Although there exists a large body of research on falls in older people, this does not address the issue of how elderly people themselves perceive and construct risks of falling, in what ways risk is felt to be shaped by broad and specific social factors and contexts, and how differing and complex constructions might affect how risk is both assessed and managed by and for elderly people. This report presents the results of a study, The construction of the risk of falls in elderly people, which was commissioned by HEBS. The research is intended to rectify this imbalance, and has used qualitative methods to explore lay and professional constructions of the risk of falling in elderly people. It is hoped that the findings will inform the development of accessible and acceptable intervention programmes to reduce falls.

Acknowledgements

As ever, we are indebted to a number of individuals and organisations for their help with this research. The interviews and focus groups were conducted by Alan Ross, Katrina Turner and Archana Srivastava: I am very grateful to them for the skill, sensitivity and useful insights. Dr Srivastava negotiated access to the Asian elders interviewed in the first phase of the study, and conducted, translated and transcribed the interviews for us. Irene Miller helped to organise focus groups and acted as scribe for most of the groups. Christine Sheehy conducted the literature search and prepared the background material for the literature review. Sue Scott gave consultant advice, and assisted with the literature review. Within Scottish Health Feedback, Elizabeth Burchell, Ann Rennie, and Kaye Milne transcribed the interviews and focus groups with speed and accuracy. We would also like to extend our thanks to Maureen O’Neil, Director of Age Concern (Scotland), and to Anne Munro, Community Development Worker with the Pilmeny Project in Leith who facilitated access to community groups and organisations.

We are particularly grateful to all those "older people" who agreed to take part in the study, and were so willing to share their views and experiences.

1. Introduction

1.2 Lay theorising about health

Milburn (1996) has pointed out that health promotion practices and interventions are likely to be informed by implicit theories or assumptions of causation and prevention. She goes on to suggest that there is a need to develop theories (on which interventions are founded) which are based on "lay structures of thought and behaviour which are integral parts of everyday health-relevant behaviour" (Milburn, 1996: p42). Understandings of risk and the ways in which individuals do or do not modify their behaviour or their environment are inevitably complex and do not necessarily conform to professional assessments of risk. Professional perspectives, in turn, are often based on population-based epidemiological data about the distribution of an event and assume that risk is a matter merely of probabilities (see, for example, Calnan and Royston, 1997). This perspective does not acknowledge the differing and valid constructions by themselves and the lay public. Qualitative research suggests that individuals construct their own and others' risks in complex ways which combine personal experience and observations with official and public messages in a manner which may challenge 'scientific' explanations (Davison et al, 1991). Implicit ideas of personal responsibility for health are embedded within health promotion theory and practice. It has been argued that there is a need for health promotion to respond to "everyday embodied lay experiences" which challenge these normative constructions (Watson et al, 1996). Moreover, lay constructions do not remain static but are constantly re-evaluated in the light of changing contexts (Milburn, 1996 op cit ) and over the course of the lifecycle (Backett and Davison, 1992).

Many factors can influence the data produced in research: this applies to quantitative and qualitative research. We have already considered issues directly associated with researching the elderly, but there are broader issues affecting what people say in research contexts. In particular, Cornwell (1984) has shown the importance of understanding the ways in which respondents present both "public" (or what they believe to be publicly acceptable) and "private" (personal and individualised) accounts in a research context. Both forms of account are important; both reveal some of the complexities governing beliefs and behaviour. Cornwell's research in East London was able to use multiple interviews over time to unpack peoples' narratives.

1.3 Implications for the research: methodological considerations

It was felt that the use of a variety of approaches to data gathering with different respondent categories was likely to be the most fruitful way to explore shared and individualised, and public and private constructions of risk in older age.

In particular, the initial proposal put forward was to use both focus group techniques - possibly bringing together friendship groups - and in-depth interviews: the former were seen as likely to produce data revealing some of the ways in which older people talk about falls and risks of falling with each other. These were likely to include public, socially constructed and constrained accounts but which might give insights into the language used to consider risk in general, and in relation to falls in particular. The in-depth interviews offered opportunities to explore the private views of the elderly person, where they can be freer from the constraints of the "majority" view and those of their relatives.

1.4 Research design

The study had three distinct, but linked phases.

The first stage of the study was a review of the literature and considered four domains:

• An assessment of different strategies for research with older people, and the implications for the study
• A review of the literature pertaining to the causes, consequences and prevention of falls in older people
• A review of health promotion work with older people, and discussion of the implication for falls prevention programmes
• A review of the largely sociological literature relating to risk and its construction

The literature review informed the approach to data gathering: including the definition of samples and recruitment to the study, the methods to be used, the content of interview schedules, and the analysis and interpretation of data.

The second stage of the study involved data collection with older people and professionals. The methods used were influenced by the material emerging from the literature, and included personal in-depth interviews and group interviews. The aim of this first, exploratory stage was to elicit from lay elders and professionals general constructions of falls and the risk of falling in relation to the definition, attribution and prevention of falls. The approaches to lay elders were via established groups and organisations working with older people. Professionals were identified in a number of ways: different key professional groups working with older people were identified, but we were also led to particular individuals or groups through these and other informal contacts. For example, it quickly became clear that certain professional groups (such as occupational therapists and physiotherapists) were regarded and regarded themselves to be the principal professionals with a remit to work with older people who had had a fall, or were deemed at risk of falling. Other professional groups also staked a claim – Chiropodists were one such grouping – and we allowed the sample to develop flexibly in this way believing that this approach was itself a reflection of the ways in which falls and risk were constructed by professionals.

The third and final element of the study aimed to validate and further explore those constructions which emerged from the stage 2 interviews. The initial proposal was that this would entail a series of case studies comprising interviews with an older person defined as "at risk of falling" and with key "others" involved in their care – such as a spouse or GP. As the study progressed, however, it became increasingly clear that this would be an inappropriate stratagem: defining risk would inevitably be by someone other than the potential lay respondent and, furthermore, would focus the study on those who were already in contact with health or other services. The study is particularly concerned to identify the potential for primary prevention of falls: a focus on older, already falling individuals misses those "pre-fallers" who might be the relevant target group for any intervention and whose perspectives are especially important.

1.1 Background

Falls are the most common cause of accidental death at home among those aged 75 or more in Scotland (HASS, 1995; Scottish Office, 1998) and account for approximately 3500 hospital admissions and 13500 new out-patient visits (Registrar General, 1997). The incidence of falls rises with age (Campbell et al, 1990) and, although the majority of elderly people who fall do not seek medical help, it is estimated that there are around 1 million falls in and around the home a year (HEBS, 1997).

There is a vast, largely epidemiological and clinical research literature focusing on falling in older age. A wide range of physical, social and psychological factors associated with falls have been identified: physical or physiological correlates of falling include impaired balance (Thornby, 1995) and associated links with medication (Monane and Avorn, 1996); poor muscle strength, impaired visual acuity and other physiological factors (Lord et al, 1994). Psychological factors – particularly lack of confidence (Myers et al, 1996), a fear of falling itself (Arfken et al, 1994), and previous experiences of falls (Luukinen et al, 1995) - have all been linked to increased risks of falling. Hazardous environments have also been implicated as a cause of falls and in injuries incurred through falling (Campbell et al, 1990; Healey, 1994). Falls can have a devastating impact on an older person, affecting not only their physical well-being but also their emotional health and their capacity for independent living (Cwikel and Fried, 1992; Walker and Howland, 1991; Tinetti and Powell, 1989; Tideiksaar, 1993).

Reviews of falls prevention strategies (see, for example, Gillespie et al, 1997; Oakley et al, 1995; Kannus, 1999) all tend to confirm that there are some benefits for older people, both in terms of preventing further falls and minimising injuries associated with falls, of weight-bearing exercise to improve balance (Buchner et al, 1997a and 1997b) and to strengthen bone density (McMurdo et al, 1997).

These research efforts, however, mostly do not address the issue of how elderly people themselves perceive and construct risks of falling, in what ways risk is felt to be shaped by broad and specific social factors and contexts, and how differing and complex constructions might affect how risk is both assessed and managed by and for elderly people.

This report presents the results of a research investigation, The construction of the risk of falls in elderly people, which was commissioned by HEBS to rectify this imbalance. The research has used qualitative methods to explore lay and professional constructions of the risk of falling in elderly people. It is hoped that a better understanding of these different perspectives – including exploration of the language used to define and describe falls, a better understanding of the context in which falls occur and their impact on individuals, and of perceptions of prevention - will inform the development of intervention programmes to reduce falls, which are accessible and acceptable to older people. The research is based on the premise that lay perspectives must underpin and inform any health education and health promotion intervention, something which has generally been lacking in much health promotion work with older people.

2. Review of literature

2.2 Search rationale

In recent years, there have been a number of systematic reviews of the falls literature (for example: Ashkam et al, 1990). We have not attempted to replicate those searches but have used the material contained in those reviews in this paper, up-dating where appropriate and discussing the conclusions of those reviews and the material presented in them relation to our particular concerns. We review key approaches which have been used in studies of elderly people, paying particular attention to issues of reliability, validity and acceptability. The health education and health promotion literature was examined for examples of good or effective practice interventions where elderly people have been the target population: again, we have been particularly concerned with issues of effectiveness and acceptability. The largely sociological literature relating to risk conceptualisation has been reviewed, and is considered in relation to the implications for understanding the beliefs and behaviour of older people. It is our impression that the literature on falls in the elderly is, overwhelmingly, written from a medical and/or professional perspective: the perspective of the older person is almost entirely lacking.

While statistical approaches may yield valuable data about the inter-relationships between particular variables, they cannot explain how variables might interact dynamically with each other at the individual or family level: nor can strictly quantitative methods be used in ways which offer insights into how beliefs and behaviour are integrated into and derive from everyday, lived experiences (Cornwell, 1984; Milburn, 1996). The exploration of lay beliefs can only be achieved by using qualitative approaches, which allow respondents to articulate complex, possibly contradictory expressions of their beliefs and experiences.

Inevitably this review, therefore, places a greater emphasis on the studies which have used qualitative approaches to the study of older people. There are, nevertheless, important lessons to be derived from studies which have used quantitative or structured approaches. Although older age may be associated with infirmity, illness and physical and mental impairment these are not inevitable consequences of ageing. It is, nevertheless, important to appreciate the extent to which frailty may affect a person's willingness and ability to participate in research studies: these insights tend to emerge from studies using structured approaches.

This literature review spans four distinct and extensive areas of research and precedes the main data collection elements of the study. We do not, therefore, make any claim that this can be a complete review of each of those four areas. What we have tried to achieve, however, is a purposive review of the relevant literature which focuses on those issues of particular concern for the wider research effort. We have not attempted to replicate existing effectiveness and other reviews, but have used their findings and conclusions within this review. Although the review may be used to inform various aspects of HEBS' work with elderly people, we were guided in our investigation by the need to ensure that:

• the methods we proposed to use in later stages of the falls study were appropriate and would be acceptable to elderly respondents and, if necessary, could be adapted to take account of the research literature.
• the content of interview schedules and guides reflected the range of views among professionals and lay elderly people about the definitions, causes and views of prevention of falls
• the data emerging from the study could be considered within a broader context of health education/health promotion interventions for elderly people
• the data collection process and the data analysis would be informed by conceptual debates around issues such as risk, risk assessment and risk management.

2.3 Search methodologies

We used a variety of methods, including computer databases, hand-searching of journals, tracing via previously published papers, and accessing specialist libraries and research centres to access published research literature and to locate any relevant unpublished material.

Databases and other sources used for the literature searches included Medline; Sociofile; Science Citation Index; Social Science Citation Index; HEBS CD-ROM; PsycLIT; CINAHL; and ASSIA. Specialist research centres and agencies were also approached for access to their libraries and publication lists.

2.4 Research involving older people

Although there is a considerable literature concerned with the assessment of the physical and mental functioning of older people, there is comparatively little on the practical problems of eliciting information for research purposes from older people.

It has been estimated that approximately 10% of those aged over 65 and only 20% of those aged over 80 may show evidence of intellectual failure (HAS, 1982). It would be an ageist fallacy, therefore, to assume that advancing age is inevitably associated with either physical and intellectual frailty: indeed, such a view may inhibit the development and provision of appropriate services for older people (Cornwell, 1989).

Nevertheless, there can be very real difficulties associated with interviewing frail, elderly people and these may affect the quantity and quality of the information which is gathered. The elderly may need more attention and interviewer involvement, and may regard some issues as sensitive in ways that younger people may not; the need for greater interviewer involvement can lead to bias. In addition, there may be problems of forgetfulness, poor concentration, a lack of lucidity and confusion (NCC, 1990), an elderly respondent may try to conceal a lack of understanding or problems of sight or hearing and, if particularly dependent, may prefer to let others answer on their behalf (Hoinville, 1983). These difficulties are not insurmountable, but do require particular sensitivity on the part of researchers. In general, participation in research by older people – whatever the method – is likely to be greater when the research studied (Hebert et al, 1996). In this, the "elderly" are no different from other groups in the population.

Self-completion and questionnaire-based methods

Surveys of elderly people using postal and other self-completion questionnaire methods are likely to under-represent those with cognitive impairment (Bowns et al, 1991), or with physical impairments (Barber et al, 1980; Landry et al, 1988; Reuben et al, 1995) or specific disabilities such as problems with vision (Toner et al, 1988). Older respondents may be not reveal functional disabilities on a postal questionnaire (McHorney et al, 1994) and are likely, therefore, to underestimate a respondent’s health problems (Doll et al, 1991). Postal/self-completion methods will, however, achieve an overall higher response rate than telephone surveys (McHorney et al, 1994) and may be better than face-to-face methods for gathering certain kinds of factual details such as factual sensitive information, which older people feel embarrassed to reveal in a personal interview (Doll et al, 1959). Attempts to assess the reliability of postal questionnaire responses suggest that responses are reasonably stable and that age per se is not consistently related to the consistency of responses over time (Boult et al, 1994).

Interviews of elderly people by telephone have been found to be a reasonably reliable means to obtain reliable information about functional status, both by lay interviewers and by health professionals (Korner-Bitensky and Wood-Dauphinee, 1994;1995). There are likely to be understandable difficulties associated with telephone methods for those with hearing impairment, and recruitment to the method via personal interview prior to the telephone contact has been found to be a prime factor in ensuring participation (Tierney and Worth, 1993). However, compared to younger people, response rates to telephone approaches among older people are likely to be lower, to result in a higher rate of uncertainty of response ("don’t know" responses), and to require more interviewer assistance (Herzog and Rogers, 1988). The least acceptable form of self-completion methods appears to be diaries. Even when maintained over a defined period and covering specified areas they do not appear to be a popular or particularly reliable or valid means of data-collection among elderly people (Cartmel and Moon, 1992; Rosner et al, 1992).

Structured approaches to data-collection – such as postal questionnaires – can yield important information but, as we have suggested, have their limitations in terms of the reliability and quality of the data they produce. What such approaches have in common is a tendency to focus on pre-defined issues or topics, which may or may not be salient and relevant to a person’s subjective concerns (Gearing and Dant, 1990).

Focus group and group interview methods

Focus group or group interview methods have only been used in a small number of studies involving elderly people - largely because of a belief that older people would not be able or willing to participate in a focus group discussion (Gulanick and Keough, 1997; Ivanoff et al, 1996). Group methods have been used in a variety of settings and to gather very different kinds of data with older people. These include Nominal Group Processes which use a structured approach to elicit information (see, for example a study exploring the perception of dental health among elderly people - Marinelli et al, 1982),User Forums which have been employed to gather the views of older people in defined localities about services in their area (see Barnes et al, 1994; Pomfret, 1997) and other approaches such as Q-sort techniques (see, for example, Betts, 1985). Whatever the actual approach used, these group methods are mostly seen as enjoyable by participants (Kaufman, 1996).

Studies which have used focus groups with older people highlight some of the particular requirements for group work with older respondents. It is suggested that there is a particular need to ensure, first, that each participant has been well prepared for the group discussion by explaining individually the purpose of the study to allow questions to be answered and any fears allayed (Yates et al, 1995); and, second, that the physical environment has been laid out so that participants can see and hear easily (Heller et al, 1990). Being part of homogeneously defined group may reduce the anxiety of participants (Gray-Vickery, 1993) and is likely to be most productive (Heller et al, 1990, Ginn et al, 1997). Recruitment of elderly people to a focus group study is likely to be more effective and less threatening if initial contact is via established groups (Crockett et al, 1990), and by telephone or personal contact rather than by letter (Heller et al, 1990).

One-to-one interviews

Whereas the group interview or focus group discussion allows exploration of shared views and offers insights into the ways in which individuals talk about particular issues, the one-to-one interview allows in-depth examination of an individuals views or experiences unhindered by group processes. Un-structured (or semi-structured) interviews have been found to be powerful tool for eliciting the views of elderly people (MacPherson et al, 1988) and for exploring the meaning that individuals attach to events (Ramhoj and de Oliveira (1991). The more structured the interview, the less opportunity there is for a respondent to expand and extend their narrative. It has been suggested that biographical approaches, in which an elderly person is able to talk about events in ways that best suit them (Gearing and Dant, 1990), and which follow a natural sequence which allows events or a sequence of events to unfold are particularly acceptable to older respondents (Bray et al, 1995). Interview approaches which have a conversational feel are also preferred by elderly respondents (Montazer et al, 1996).

The quality of data generated by interviews with older people is generally comparable to that obtained by interviews with younger age-groups. Older people may have slower, but not necessarily lesser intellectual functioning (Domarad and Buschmann, 1995). Only the very old or those suffering from intellectual deficits may be more likely to have severe memory loss, interviews are otherwise comparable with interviews conducted with younger people and are likely to yield equally reliable information (Bury and Holme, 1990). Interviews with older people may take longer than those with younger people (Wingrove, 1987) and interviewers needs to be even more flexible throughout the interview to accommodate any deviations on the part of the respondent (MacPherson et al, 1988).

If gender-sensitive topics are to be discussed, matching the gender of interviewer and respondent can help to make the respondent feel more comfortable (Domarad and Buschmann, 1995). The presence of a third person during the interview may inhibit a respondent (MacPherson et al, 1988), particularly if the interview is trying to elicit material around sensitive or personal topics (Greene et al, 1994). Overall, however, any limitations associated with possible frailty tend to be offset by a high level of co-operation and interest on the part of older interviewees (Gibson and Aitkenhead, 1993).

In relation to falls in particular, recall may actually be better if a longer rather than a shorter time frame is used. Cummings et al (1988) found that falls which resulted in no or minor injuries were less often recalled and asking about a shorter and more recent time periods did not improve recall. It is suggested that recall of a fall will be enhanced if the investigator links it temporally to a memorable event.

Rapport is crucial to the success of an interview, and may be of particular importance when interviewing older people (Gearing and Dant, 1990), and should be established at the recruitment stage (Wingrove, 1987). It has been found that telephone contact before an interview is seen as reassuring and improves participation (Bergsten et al, 1984). Direct recruitment rather than via newsletters or flyers is a more effective recruitment strategy (Greenwell and Spillman, 1996). Access is likely to be most effectively negotiated if the initial point of contact is an established group (Crockett et al, 1990).

Enhancing the participation of older people in research

Although there is clear evidence that older people are co-operative, involved and reliable respondents in research, it is also clear that particular approaches are more acceptable and appropriate and there are clear lessons to be drawn. It has been suggested that interview studies with elderly respondents place a number of demands on the interviewers (Hoinville, 1983). In particular, interviewers require extensive training, including training to cope with long and possibly stressful interviews; the social skills of the interviewer are crucial – it may be necessary to match gender if sensitive topics are being discussed and rapport must be established early in the process; the salience of the topic will affect how involved the elderly person feels in the interview situation; and, finally, interviews should not be over-complex and should use less structured approaches which allow respondents’ narratives to flow conversationally and with reference, if necessary, to marker events to aid recall. Group approaches should bring together individuals who are as homogeneous as possible, and recruitment to research is more likely to be acceptable if the topic is seen as salient and if contact is made via an already established group or network.

2.5 Falls among older people

The epidemiology of falls

Constructing an epidemiology of falling is by no means straightforward: a number of factors mitigate against establishing a complete picture of the patterning of falls by age, social class, or even by outcome. First, there is no standard clinical definition of a "fall", which may be classified in a variety of ways with different kinds of falling often associated with different causes or "risk factors" (Lach et al, 1991). Nor is there a consensus about how different falls should be classified (Rubenstein et al, 1988). Second, the sources of information about falls varies considerably, as does the time-frame and age-groupings on which estimates are based. Nevertheless, falls are far from being inevitable "adjuncts" to the ageing process but are the result of "a combination of medical, environmental, psychological and social factors that interact with physiological age-related changes" (Cwikel and Fried, 1992). Cwikel and Fried argue, further, that there is a need to construct a social epidemiology of falls, and this should be an important background for the development of preventive work.

[i] Defining falls

There is a lack of precision in falls terminology (Steinmetz and Hobson, 1994) and this inevitably hinders conceptual development in falls research. Defining falls as "an unexpected loss of balance resulting in coming to rest on the floor, the ground, or an object below knee level", Lach and her colleagues (1991) were able to classify subject-reported falls reliably into one of four categories: "intrinsic "falls which were falling events where the fall is associated with a mobility or balance disorder; "extrinsic" falls were those associated environmental factors such as tripping over an object or slipping on a wet surface; "non-bipedal" falls were those where the subject was not standing and say, fell from a chair; finally, there was fourth category which comprised all those falls which could not be classified into one of the other three categories – for example, because the subject did not know or was unclear about what had happened. The results from this and earlier studies (Morfitt, 1983) suggested that extrinsic falls were more common at younger ages, while intrinsic falls were more often observed at older ages.

Very few studies have attempted to derive definitions of falling which are based on the subjective experience of older people themselves, although the need for an understanding of older person’s beliefs about falling has been pinpointed as a pre-requisite for preventive work (Cwikel and Fried, op cit). One small-scale study has involved older people in an attempt to understand their perspective. Residents in a geriatric nursing home who were regarded by nursing staff as "frequent fallers" were asked about their experiences. The definition of a fall which was used was of an "abrupt position change to horizontal, knees or sitting position". However, this simple definition did not resonate with those individuals, who saw themselves as "slippers", "trippers" or "sliders", but definitely not "fallers" (Wright et al, 1998).

[ii] Sources of information

In addition to the use of different definitions of falls, the collation of data on falls may differ in terms of its source (for example, gathering data based on hospital admissions following a fall, Gialloreti and Marazzi, 1996), or via self-report (see, for example, Hernden et al, 1997; Faizy and Reinsch, 1994). The classification of age-groups to define older age may also vary, and different studies may base rates of falling on different time periods. This is of particular relevance if the data are based on self-report and may, therefore, be affected by accuracy of recall of falls (Cummings et al, 1998). There is, therefore, likely to be a substantial underestimation of the number of falls experienced by the elderly, with the majority of falls not recorded at all.

Lach et al (1991, op cit) estimated, on the basis of self-reports gathered prospectively over a three-year period, that 30% of community dwelling elders aged 60 or more would experience a fall in a year. A number of studies have, however, produced similar estimates of the rate of falling among community-based elders (Dargent-Milina, 1995). Tinetti and Speechley (1991) reported a rate of falling of 32%, but with considerable variation by the health status of the older person. Whereas only 17% of elders defined as "vigorous" experienced a fall in the follow-up year, 52% of those defined as "frail" did so. Graham and Firth, (1992) conducted a postal survey with follow-up interview of registered GP patients aged over 65 to gather information about home accidents and injuries which had occurred in a one month period: almost 8% had experienced a n accident in the month, of which two-thirds were classed as falls. Three-quarters of the incidents resulted in an injury, but less than a quarter were reported to medical services.

[iii] Routine data sources

Systematic information about the possibly more serious falls can be obtained from the SMR1. This is a form completed when individuals complete at least one night in hospital, although even these data are problematic and subject to bias. Admission policies may vary and it has been shown that where a population is more dispersed geographically, an older person is more likely to be admitted to hospital following a fall (Truman, 1995). The Registrar General's mortality data may record the cause of death as an "accidental fall", but difference in English & Welsh and Scottish rates of death from falls may be due to differences in recording. For example, in England, there is a tendency to record death from falls as due to osteoporosis to avoid an inquest (Truman, op cit).

The HASS (Home Accident Surveillance System), compiled under the DTI, collected information from the A&E departments of a small number hospitals (one in Scotland) documenting accidents and rates of falls by age, sex, the nature and apparent cause of the accident, and produces national estimates based on these data (Department of Trade and Industry, 1997). This represents one of the most comprehensive data sets available, but is again limited by the source of the information (hospital A&E) and by definitional constraints. Inevitably, therefore, constructing an "epidemiology of falls" is subject to caveats of definition, source of information, and other biases.

[iv] Patterns of falling

What the available data indicate is that rates of falling among community dwelling elderly people increase with age, particularly over the age of 75 (Tinetti et al, 1988; Norton et al, 1997; Darget-Molina, 1995 op cit). The number of falls per 100 person years has been estimated at 47 for those aged 70-74 rising to 121 for those aged over 80+(Campbell et al, 1990). It has been estimated that most people aged over 65 can expect to have a home accident each year and over half of these will be a fall (Graham and Firth, 1992). Men and women appear to be equally likely to experience falls, but men were more likely than women to fall outside and at greater levels of activity: that is, when engaged in activities such as running, carrying or climbing rather than merely standing or walking (Campbell et al, 1990, op cit). This pattern was evident for all age-groups. Women's falls occur more often in the home environment, but whether this is due to differences in the kinds of activities men and women may engage is not clear.

Factors associated with falling

A recent systematic review of the literature on falls and falls prevention has identified over 400 potential risk factors or correlates of falling (see NHS Centre for Reviews and Dissemination/Nuffield Institute for Health Bulletin, 1996). It has been suggested that the risk of falling increases with the number of "risk factors" identified (Tinetti et al, 1988, op cit; Graafmans et al, 1996), and the experience of a previous fall is probably one of the best predictors of a future or further fall (Howland et al, 1993; Gialloreti and Marazzi, 1996; Luukinen et al, 1995; Luukinen et al, 1997).

Different studies have used a range of methodologies on different study populations, employing different definitions of falls and fallers and subject to biases due to inaccuracies of recall. However, the evidence increasingly suggests that falls in older age are multi-factorial (Rizzo et al, 1996), and may be different for different sub-groups or categories of older person (Graafmans et al, 1996 op cit). The research literature highlights those factors which are most strongly and consistently implicated in falls – either in their own right or in combination with other factors.

[a] Environmental factors such as loose carpets, unsafe stairways, poor lighting or ill-fitting shoes are estimated to contribute to between a third and a half of falls among community dwelling elderly people (Tinetti et al, 1988, op cit: NHS Centre for Reviews and Dissemination/Nuffield Institute for Health Bulletin, 1996, op cit), and may be the most important factor in falls in the "young elderly" – that is, up to age 75. Beyond that age, disease processes or physiological causes linked to failing health are stronger determinant of falls (Morfitt, 1983). Environmental factors are more important in first falls but are less important in each subsequent fall, and are more often the antecedent of a fall in an active than a frail older person (Tinetti and Speechley, 1991 op cit; Northbridge et al, 1995).

[b] Physical changes due to ageing contribute substantially to falls, with possibly only a quarter of falls occurring at home due to obvious environmental factors (Norton et al, 1997). Increasing age, but more importantly frailty associated with physical deficits have been linked to increased likelihood of falling: these include impaired vision and ophthalmic diseases, which may cause a decline in visual functioning due to reduction in reaction times to changes in light intensity and lens opacity which may affect a person's ability to distinguish between similar colours (Dolinis et al, 1997; Grisso et al, 1991, McMurdo and Gaskell, 1991; Luukinen et al, 1995). Impaired hearing (see Tinnetti and Speechley, 1991) has also been implicated in falls.

Poor balance and gait have been identified as a major factor or antecedent of falls, particularly among those with already poor physical health in which impaired balance is a symptom of illness (Overstall et al, 1977; Thornby, 1995; Myers et al, 1996; Vellas et al, 1997; Maki 1997; Campbell et al, 1992). Poor muscle strength may also inhibit balance (Lord et al, 1994) and accelerated bone loss have both been implicated in falls (Thornby, 1995; Dargent-Molina et al , 1996). Changes in posture and gait linked to problems with feet (for example, bunions or corns) may also be implicated in falls (Dolinis et al, 1997: Tinetti et al, 1988). Mobility impairment, in general and including impairment of balance, leg extension strength and gait, has been linked to falls and, particularly to recurrent falls (Graafmans et al, 1996 op cit). Efforts to improve balance and gait (for example, Buchner et al, 1997a) or increase bone density through weight-bearing exercise (for example, McMurdo et al, 1997) have been shown to prevent falls.

Specific diseases particularly, as we have suggested, those illnesses affecting some part of the balance mechanism or the integrity of the cerebral circulation such as epilepsy, Parkinson's disease, stroke/ cerebrovascular disease, neuropathies, cardiac arrhythmia, diabetes have been associated with increased risk of falling (Campbell et al, 1981; Campbell, 1992; Downton, 1994). Approximately one in ten falls may occur during an acute illness episode (Tinetti et al, 1988 op cit)

The use of prescribed medication may also affect balance and concentration (Burket et al, 1995): anti-depressants, benzodiazepine, analgesic sedatives tranquillisers, diuretics, laxatives have all been associated with increased risk of falling (Tinetti et al, 1988 op cit; Dergent-Melina 1995).

[c] Psychological factors have been shown by many studies to increase the risk of falling, with fear of falling itself linked with falls (Myers et al, 1996, Fessel and Nevitt, 1997; Maki, 1997; Howland et al, 1993; Walker and Howland, 1991; Gallagher and Brunt, 1996; Burker et al, 1995; Vetter and Ford, 1989).

Fear of falling increases with age and is more common in women (Arfken et al, 1994). Fear of falling is associated more with emotional status than physical status, although it is often carers who are more fearful of falls in those for whom they are looking after than elderly person themselves, and may be carers who try to limit their activities (Liddle and Gilleard, 1995). People who have underlying balance or gait impairment, recurrent history of falls over a short time period and physical injury or functional loss as a result of falls are those most likely to fear falling (Tideiksaar, 1993). Living alone and suffering prolonged post-fall lie times are, perhaps not surprisingly associated with a fear of falling (Tideiksaar, 1993 op cit).

Fear, in turn, has its psychological sequalae and may result in dependency and low self efficacy (Tinetti and Powell, 1989), and an unwillingness to lead a full life, loneliness, isolation and depression (Rynanen, 1994). A small-scale but very relevant study conducted in Edinburgh suggests that some older people are almost fatalistic about the risks of falling, accepting them as a concomitant of ageing (Conway, 1996).

Falls prevention

There have been a considerable number of interventions which have aimed to assess the unique impact, or any combination, of a range of interventions on falling. These include, exercise (Hornbrook et al, 1994; Lord et al, 1995), home assessment and surveillance (Rubenstein et al, 1990), shoe type (Robbins et al, 1992), nutritional supplementation (Province et al, 1995), and health education and home safety advice on rates of falling in older people. The most extensive of these are the inter-linked FICSIT interventions (Frailty and Injury Co-operative Studies of Intervention Techniques), conducted across a number of sites and including community and institutional dwelling elders (see, for example, Hornbrook et al, 1994; Tinetti et al, 1994; Buchner et al, 1997). Each site explored the role of particular exercise interventions on falls prevention. The key finding from these studies is that interventions which aim to increase particular exercise regimes can make a modest impact on rates of falling, and that balance training is the key intervention likely to produce a reduction in rates of falling (Oakley et al, 1995).

Other studies have evaluated the role of exercise – either on its own or in combination with other interventions. The variety of interventions inevitably makes comparisons difficult. However, there have been a number of effectiveness reviews evaluating accident and falls prevention strategies or programmes which have focused only on interventions which used Randomised Controlled Trials (RCTs), where there was an adequate follow-up period, and where the outcome measures were based on actual falls or fall-related injuries rather than on possibly intermediate factors such as balance.

Two reviews of the falls prevention literature are of particular value and are the focus of this section: that published by Effective Health Care (1996) which, in turn, was based on a review carried out by Oakley et al (1995), and an extensive review published by the Cochrane Library (Gillespie et al, 1998). As these are both limited to studies which meet the strict criteria of the NHS Centre for Reviews and Dissemination, we do not intend to repeat – in detail – their findings. Instead, we have summarised the conclusions of these reviews which assessed over 30 trials, and consider their implications for the present study. Other falls prevention studies are considered later in the report in the section concerned with health promotion for older people.

The effectiveness reviews conclude that the causes of falling is multi-factorial and the evidence suggest that multifactorial interventions are the most effective, with some factors more amenable to change than others (Tinetti et al, 1994). In general, it would appear that interventions focusing on single "risk factors" are the least likely to be effective, whereas those which target a range of factors and are based on individualised assessment are the more likely to be associated with a reduction in falls for those individuals. Exercise alone may not have an effect on injurious fall and meta-analysis of the FICSIT (Frailty and Injuries: Co-operative Studies of Intervention Techniques) trials could not definitively answer this question (Trilling and Tanvir, 1995), although balance training in general (Wolfson et al, 1993: Province et al, 1995), and T'ai Chi, in particular, has been cited as an especially effective approach (Wolf et al, 1996).

The reviews find little evidence to support the view that any one single intervention can effectively prevent falls or reduce injury. Balancing, low impact aerobic or muscle strengthening exercise was found to have some impact on rates of falling but there is no consensus as to the most effective means of programme delivery, although evidence from the FISCIT trials suggest that multi-factorial and targeted interventions are likely to be cost-effective in terms of reducing the health care costs associated with falls (Rizzo et al, 1996 op cit).

All of these interventions were focused on those who were deemed most at risk of falling because of a previous falling experience. There has been little consideration of the primary prevention of falls: that is, the prevention of a first fall. Cwikel and Fried (1992) outlined three components for the primary prevention of falls in the pre-fall stage: first, "identification of elderly persons at high risk for falls" on the basis of an assessment of known demographic, environmental and psychological factors, age-related physical changes, and treatable medical conditions associated with falling. The authors acknowledge, however, that there is no validated fall risk index which can discriminate between low and high risk individuals. The second component, based on evidence about the likely preventive role of weight bearing exercise, is the encouragement of physical and social activity among pre-fallers. Thirdly, it is suggested that older persons receive accident prevention education. The role for primary prevention of falls has never been explored in depth, although it has been suggested that secondary prevention may be more cost-effective in reducing falls (Downton, 1994).

There are two important caveats to the extent to which the conclusions of the reviews can be extrapolated. First, few of the interventions considered in the reviews were conducted in the UK and, as we discuss in a later section, the role of socio-cultural factors in the development of health promotion initiatives should not be side-lined. Second, a crucial gap in the planning, evaluation and implementation of any of the cited interventions is the perspectives of older people themselves (Effective Health Care Review, 1996).

2.6 Health Promotion with older people

An ageing population

It has been argued that "..healthy ageing be viewed asa function of successful problem-solving and as a functional, self-definedstatus that hinges on inter-dependence, power, control, and environmentalfit" (Beckinham and Watt, 1995). There is, as a recent review published bythe Health Education Authority states, a "strong case for promoting thehealth of older people" in ways which promote positive images of ageing,promote self-help and mutual aid within an older person’s community, andwhich help maintain social engagement and an active life (Killoran et al,1997).

As a greater number of people live longer, the UK has anincreasingly ageing population: it is estimated that within thirty years almostone in five will be aged 65 years or more. A healthier old age, which is freefrom significant physical, intellectual and emotional disability is clearlydesirable – not only for older people themselves, but for their familiesand for the health and social services which may have to bear the brunt ofcare. It is only in more recent years that health promotion efforts have beentargeted towards older people. Hitherto, there has been a view that thedisabilities associated with older age were largely inevitable and, moreover,that older people would not be amenable to behavioural/lifestyle change.

This pessimistic view of old age has, however, beenchallenged: not only are many of the health problems which are more likely tobe manifest in older age (such as cardiovascular diseases, osteoporosis,osteo-arthritis, cancers and, to some extent, dementia) preventable throughrisk factor modification (WHO, 1995; Department of Health, 1994; Grimlay Evans,1993; Orrell and Sahakin, 1995 – see Killoran et al, 1997 op cit), butmany conditions and functional disabilities are remediable. The persistence ofsocial inequalities into old age highlights the scope for improvement (Victor,1991). To the extent that there do exist variations by age, gender and socialclass (Victor, 1989) challenges the norm that old age is a time of universaland inevitable biological decline. The role of social, economic and structuralfactors in determining health over the whole of the life-cycle cannot beignored nor under-estimated. Undoubtedly, however, the greatest scope in olderage is for secondary rather than primary prevention: a narrow focus onindividual behaviour is likely to be as unproductive in old age as it can be atyounger ages.

Health promotion interventions

This element of the literature review will not detail thenumerous and diverse health promotion and health education interventions aimedat older people. There exist other reviews and discussions of this (see, andthe previous section of this report detailed some of the falls preventioninterventions. Rather, what we aim to do here is to elucidate thecharacteristics of health promotion interventions associated with the successor otherwise of interventions.

There are a number of consistent themes running through thehealth promotion literature in relation to older people. In particular, healthpromotion interventions for older people which do not address the perceivedconcerns of older people (Kaufman, 1996; Ferrini et al, 1994; Maynard, 1990),and which do not reflect individual and cultural diversity (Meeks and Johnson,1988) and, finally, which are based on single-factor, one-off and fragmentedapproaches (Lave et al, 1995; Ory and Fox, 1994; Carter et al, 1989; Wagner etal, 1994) are unlikely to be successful in the long-term. However, that doesnot imply that there exists a body of evidence about what interventions, oreven what kind of interventions, for older people do, or do not, achievespecific, or even general, health promotion goals. Indeed, it is quite clearthat the evidence such as it is, is both patchy and inconclusive.

Perceived concerns

First and foremost, the literature points to the need forhealth promotion efforts which acknowledge and build on the superficiallyobvious, but nevertheless crucial factor that older people are not somehomogeneous group but reflect great diversity in relation to health status,belief and attitude, behaviour and culture.

There is, for example, a need to understand and linkpersonal definitions of health to any health promotion effort: a message willnot be deemed relevant by older people if it is not based on and derived froman individual’s own definitional structures (Kaufman, 1996 op cit) and,where people are confused about the health messages being portrayed, they areless likely to make life or behavioural change (Ferrini et al, 1994; Carter etal, 1989). Health messages which are deemed to be relevant or salient arelikely to be ignored (Meeks and Johnson, 1988). It has been suggested thatqualitative approaches such as Nominal Group Techniques (Twible, 1992) or focusgroup methods (Ivanoff et al, 1996) can be an effective means of finding outabout the priorities and subjective concerns of older people which can informinterventions. Health promotion messages which are perceived to beindividualised and delivered at the appropriate pace for the individual arebetter understood and received (Campbell and Lancaster, 1988).

Individual and cultural diversity

The need for health promotion efforts to reflect individualand subjective concerns of older people implies that these must be not onlyindividualised, but must also reflect the cultural and social context whichshapes those concerns. A review of factors affecting older people’sparticipation in health programmes found that participation declined with age,and was linked to a range of factors including marital status, education andincome levels, gender, health status, personal or family history, socialintegration, and health beliefs: all of these factors may mask importantinter-group differences in relation to health needs and health promotionoutcomes (Carter et al, 1991; Stevens et al, 1992). Maynard (1991)stressed the need for health promotion programmes to address the needs ofethnic minority elders, who may have not only poorer health but also limitedaccess to health resources.

Older age can be associated with depression and isolation(Millard, 1983) and strategies which have as their goal improved socialintegration and activity have been advocated (Killoran et al, op cit). Inparticular, it is argued that interventions which promote the creation anddevelopment of social networks are inherently health promoting. Restoringconfidence and diagnosing depression were identified as important components ofrehabilitation programmes for older people after a fall (Campbell et al, 1992).

Multi-factorial approaches

An earlier element of this review suggested thatsingle-factor approaches to falls prevention, which did not address thecomplexity of older peoples’ lives, were less successful than those thatdid (see, for example, Tinetti et al, 1994). This finding is not limited tofalls prevention, but is relevant as one might expect across the spectrum ofhealth promotion interventions in older age. Where the focus is on the"whole person" rather than on a specific dysfunction there appear tobe long-term benefits. For example, a controlled trial which involved nursevisits to frail elders in their own home over a three year period and where thefocus was on a range of issues (such as nutrition, health care, exercise,stress) in addition to standard care found that those who had received onlystandard care were less likely to still be living independently (Hall et al,1992). One-off interventions – especially those which focus narrowly onprofessionally defined risk factors - have not been found to be associated withlong-term change or benefits (Lalonde et al, 1988; Wagner et al, 1994).

On the other hand, a falls prevention programme (Stay OnYour Feet) in Australia which was not a Randomised Controlled Trial and,therefore, excluded from the effectiveness reviews described earlier containedwhat may be important more general lessons for health promotion efforts witholder people. The researchers described a three year, community-based,multi-strategic approach to falls prevention which included awareness raising,community education, policy development, home safety measures, involved generalpractitioners and, crucially, harnessed established links between older peopleand involved older people in the delivery of the programme resulted in wideawareness among older people of the issues, and behavioural change to preventfalls (Garner et al, 1996). One of the features of this intervention, was theemployment and training of peer-group community educators. Although peereducation is most often associated with younger age-groups, there is evidenceto suggest that is feasible with older age groups (Ho et al, 1987). Asmall-scale falls education programme in the USA found that small groupteaching was more effective in stimulating behavioural and environmental changeamong older women than individual tuition (Ryan and Spellbring, 1996),suggesting that the group process may be a valuable health promotion device.

These issues are not independent: health promotion effortswhich are based on a focus on the individual and subjective concerns and needsof older people will, inevitably, result in a greater awareness of their socialand cultural roots. Moreover, the concerns and foci of health professionals arelikely to be informed by clinical and epidemiological data rather than by thelay perspectives (Ory and Cox, 1994). Once attention is on subjective concernsit becomes difficult to sustain a single factor/issue approach based on risk(usually behavioural) assessment.

2.7 Understanding risk

There is a dearth of empirical work which has exploredperspectives on risk in older age and we have, therefore, been drawn to a verydifferent literatures for this review: in particular, we have drawn on workwith young people and sexual health. We have done so partly because of theabsence of material relating to "risk" older age, but also because webelieve that there are important parallels and continuities which make thatwork relevant for this debate.

Risk has become an increasingly common frame forunderstanding late twentieth century 'Western' societies (Giddens, 1990 and1991; Scott and Williams, 1992). Such theorising draws us away fromunderstandings of, for example, accidents as fateful towards, on the one hand,the global repercussions of 'progress' which have produced the 'Risk Society'(Beck, 1992) and, on the other hand, a focus on more individualisedunderstandings of risk as a product of lifestyle (Scott and Freeman, 1995).

Expectations that, in a world governed by rationality, risksshould be calculable and avoidable are increasingly tempered by feelings ofhelplessness in the face of disaster, actual or impending: for example,Chernobyl, AIDS, BSE. It has been suggested that this state of contradictionproduces 'risk anxiety' (Beck, 1992) and, thus, a situation where people canunderstand themselves to be perpetually at risk. This may lead to a response inwhich people make ever greater attempts to limit the risks, whether bymodifying their own lives or by making ever greater demands on experts tomanage the world and its vicissitudes on their behalf.

The extent to which such conceptual and theoreticalunderstandings of risk which distinguish between public dangers and privatised,individualised risks (Scott and Williams, 1992) actually have salience foreither lay theorising or everyday practice is yet to be fully explored throughempirical research (Scott et al, 1998).

At different points in the lifecycle, the balance betweenrisks and dangers on one hand and living a 'normal' life on the other hand,might be reconstructed depending on dominant presentations of risk at any onetime for particular groups (see, for example, Roberts et al, 1992; Hart et al,1992; Davison et al, 1992) . Beckinham and Watt (1995) have argued, forexample, for a need to understand older persons’ decisions to defyprofessionals’ assessments of the risks they face as health enhancingrather than health damaging acts on the part of the older person. Inmaintaining personal autonomy, the elder may be adopting a successful copingand healthy strategy and raises issues of appropriate professional control.

Recent social theory has conceptualised risk anxiety as asocial state engendered by an increasing lack of trust in both the project ofmodernity - the expectation of progress, improvement and fulfilment of hopesand dreams - and expert knowledge’s (Giddens 1990, 1991; Beck 1992) Modernsocieties can be characterised, in part, by risk taking and risk minimisation:venture capital and the stock market alongside insurance and immunisation, andthis is one of their key antinomies (Scott et al 1998). It is recognised thatthe future is unknowable, while at the same time being seen as open to humanintervention.

The future becomes, according to Giddens, 'a territory ofcounterfactual possibility' and thus open to risk calculation (1991:111). Riskscome from everywhere as Armstrong (1991) has pointed out - 'from the air thatwe breathe, the rays of the sun, the multi-national petrochemical companies,from our families, our sexual partners - even the cells of our bodies may turnagainst us (Scott and Williams 1992). These anxieties can be understood asGreen (1997) suggests, in the context of a rational discourse which establishedthe expectation that both nature and individuals could be controlled for thegreater good, either through science or surveillance, or both. The concept ofrisk which currently dominates both public and private discourse can be seen tobe based on individualism rather than fate and there has in recent years been afundamental shift from the rights of individuals to have their health andwell-being protected by the state, to the responsibilities of individuals toprotect themselves from risk (Scott and Williams 1992).

Risk taking is increasing defined as a problem ofindividuals, and personal education as the solution (Green 1997). Since thedevelopment of public health as a specialist field in the latter part of the19th century, the gaze of the experts has moved through environment (sewersetc.) to the spaces between people (infection and contagion) and to the effectsof specific behaviours on individual bodies (smoking, drinking, falling over)(Armstrong 1991).

This leads us directly to the question of who defines whatconstitutes a risk or risk taking behaviour at the level of the individual. Anindustrial site which were it to break down and pour toxins into theenvironment is relatively easy to define as a risk. However the risks attachedto changing a light bulb to an older person will vary greatly with a range offactors. The interface between the professional directives to look afterourselves and the local contexts within which individuals make sense of boththe risks to their health, and the exhortations to change their behaviour hasbeen the focus of sociological analysis (Davison et al, 1992). Such researchhas clearly indicated that decisions about risk-taking are linked to thecontext of people's everyday lives and not to some set of absolute healthmessages (Hart et al 1992). Thus we need a sociological understanding not of'risk-taking' behaviour, but of how people think about risk in differentcontexts, and how this impinges on both their sense of identity and on theireveryday practices.

There is little sociological work which explores the meaningof risk to older people. However, a starting point must surely be to exploreresearch undertaken on other groups and in other contexts - rather than supposethat older people have some special relationship to or perspective on risk,simply because they are defined by others as a vulnerable group. We can draw,for example, on work which focuses attention on young people - who are oftendefined as 'at risk' but who do not often define themselves as such. To takethe example of teenage pregnancy - the most common response from you women isalong the lines of - 'it wont happen to me I'm not that type' thus misfortunecan be seen to be identified with character rather than behaviour (Holland etal, 1990). The concept of not being that sort of a girl/boy may well besuccessfully applied to the issue of older people and falls.

The concept of anticipated regret has been found to beuseful in the context of young people and sexual behaviour (Wight et al, 1997).Thus anticipating the regret which might ensue if a fall occurred whilechanging a light bulb is more likely to lead to behaviour change (Richard etal, 1995). However there is a need for detailed empirical work to explore theissues relating to – not being the sort of person who falls and being ableto plan ahead to avoid falling and this becoming the sort of person who doesn'tfall!

2.1 Introduction to review of literature

The literature review focused on four areas:

Research with elderly people: This section explored the different methods which have been used in health-related research with older people and assessing the validity, reliability and acceptability of different research approaches. Within the review we assessed the extent to which studies involving older people require particular research strategies, and considered the implications for the methods to be used in the current research. The falls study used qualitative methods and these approaches were, therefore, given the greatest consideration within this review.

Falls in the elderly, documented the epidemiological literature on falls, assessing variations in relation to different forms of measurement and research contexts. The review considered social, environmental, medical and psychological factors which appear to be linked to falling. Drawing on existing evaluative reviews, interventions and strategies to prevent falls have been considered. Finally, this section of the review explored the literature in relation to lay and professional perceptions of falls and the risk of falls, using principally published literature, but also policy documents, materials prepared by voluntary agencies, health boards and local authorities.

Health promotion with older people, documented health promotion approaches which have been used with older people (e.g. special clinics, advice, exercise programmes), assessing interventions and activities in relation to their efficacy and acceptability among older people. The review considered possible limitations to health promotion initiatives directed towards elderly people and, drawing on existing reviews of this literature, assessed the implications for interventions which aim to reduce falls or the risk of falling.

Concepts of risk. This element of the review considered the largely sociological literature ways in which risk has become an increasingly common frame for understanding late twentieth century 'Western' societies. The review explored contradictory understandings of accidents as either fateful and unpredictable or as individual products of lifestyle and choice and preventable.

3. Methods

The study had two, linked data gathering phases: the firstaimed to garner generalised constructions of the risk of falling from layelders and from relevant professionals, while the second was intended tovalidate and extend those constructions. The initial proposal was to base thesecond phase around case studies of "at risk" older people and theirlay and professional carers. However, this approach was altered as it becameclear that:

• Lay and professional constructions of falls and risk were not markedlydifferent
• The complexities of definition of "a fall" and, therefore, of afirst fall meant that there was not a clear demarcation between fallers,non-fallers, and potential fallers
• The identification of an "at risk" group entailed categorisationsbased on either researcher or professional assumptions which were likely toreflect definitional ambiguity
• A focus on pre-fallers or potential fallers and on primary preventionissues implied that an "at risk" group could not be defined, letalone identified

It was decided, instead, that the second phase should beused explicitly to test and explore common issues and meanings emanatingdirectly from the first stage of data collection. The first stage comprisedindividual and group interviews with a range of lay elders and with keyprofessionals, while the second phase involved focus group discussions with layelders in two localities.

Throughout this study, we were aware of the potentialexploitative nature of research: of "using" respondents to whom nobenefits would accrue. In order to redress this imbalance, we offered to comeback and talk about the results with participants, the organisations they areconnected with, and with other professionals. In addition, we gave theorganisations (such as community groups or day centres ) which had helped us asmall fee.

3.1 Phase 1: Data collection

In-depth individual and group interviews were conducted withlay and professional respondents The lay and professional samples were largelydefined and identified purposively to reflect a range of contexts and likelyperspectives on falling. In addition, however, we were often guided towardsparticular professional groups and individuals by those we made contact with inrecruiting to the study. To that extent, this has provided a furtherperspective on which professional groups are perceived to be the appropriatediscipline in relation to falls in older people.

Lay sample

We identified 4 categories of older person, defined asanyone aged over 60 years, that we wished to represent within the sample. Thefour groups were lay elders who were:

• Representative of an ethnic minority group, or
• Known to be frail, or
• Known to be active,
• Selected simply on the basis of age (60 and over) rather than any personal,social or physical attribute

The review of literature had indicated that recruitment ofolder people to research was most effective and acceptable via establishedorganisations with which the individual was associated. This inevitably canexclude those not involved in any formal organisation and who may beparticularly isolated or without support. However, the benefits of usingexisting structures – including informal networks – outweighed, atthis stage, these concerns.

Our definition of an older person was someone aged 60 andover, and we had hoped to recruit largely from those in younger (60 – 75years) rather than older (76 – 85 year) age groups. This was lessstraightforward than anticipated: those in the younger age groups were lessoften involved in group or other activities based on age and there were noobvious sources for sampling. This, in turn, was linked we feel to theperception among this age-group that they "were not old" (or,necessarily merely "older") and, that falling was not a particularlysalient topic. Approximately half of the lay participants were in the youngerage group (see below) and, as the data go on to suggest, even those in oldercategories did not regard themselves as old.

Asian elders were identified by an experiencedqualitative researcher with contacts with community organisations for ethnicminority groups. The researcher is a native Punjabi and Hindu speaker andconducted the group and individual interviews in the appropriate language, andthen translated and transcribed the interview data for our analysis. In all, 1group (Lay Group #5) and 3 individual interviews (Lay Interviews #7, #8, and#9) were conducted with Asian elders.

Active elders were recruited via a leisure centre.Two group interviews were conducted: one with males (Lay Group #1) and one withfemales (Lay Group #3). In addition, individual interviews were conducted witha male and a female respondent, recruited from the group attending the leisurecentre, but not included in group interviews (Lay Interviews #4 and #5).

Frail elders were recruited with help from AgeConcern, who identified a number of day care organisations/centres whichprovide, among other services, lunch clubs. A group interview (Lay Group #2)was conducted at one such centre, and two individual interviews at a differentcentre (Lay Interviews #1 and #6).

"General elders" were recruited via anolder person know to one of the researchers. She was asked to bring together a"friendship group" who would be willing to discuss the issue offalls. The group interview (Lay Group #4) was probably the most wide-rangingcarried out and was also the longest, continuing for over 4 hours. Participantsto the group were asked to recruit others for an individual interview, and twointerviews were conducted using this approach (Lay Interviews #2 and #3).

Characteristics of the Phase 1 layparticipants

Five group and nine individual interviews were conducted. Ofthe 39 participants, 14 were male and 25 female. Almost half (20/39) were agedbetween 60 and 74 years and half (19/39) were aged 75 or more. A greaterproportion of the men than the women (57% vs 48%) were in the youngerage-group, and all of those aged 80 or more were women.

Professionalsample

The initial plan was to conduct individual interviews withthose in managerial positions within particular professional categories, andgroup interviews with practitioners within the same disciplines. Initialcontact was made with individuals across Scotland, identified (from the NHSRegister) to represent a particular professional grouping.

In practice, this distinction was difficult to maintain– in part, because of the professional perspectives of those we approachedwho, either did not feel that they had anything to say on the matter becausefalls were not an issue that they as a professional group dealt with, orbecause they passed us on to someone or a discipline that they regarded as moreappropriate. In this way, we were passed to Rehabilitation teams comprisingphysiotherapists and occupational therapists, and to particular individualsinvolved in falls prevention work. We were, on occasion, contacted directly byprofessionals who wished to be involved in the research. The agencies andindividuals with whom we have been in contact are all likely to be keenrecipients of the research findings.

Group interviews were conducted with the following:

• A community rehabilitation team (physiotherapy and occupational therapypractitioners)
• Podiatrists
• Community nurses

Individual interviews were conducted with:

• Care & Repair Service Manager (Age Concern)
• Home Care Services Manager (Local authority, Social Work Dept)
• Occupational Therapy Services Manager (Health Board)
• Occupational Therapy Practitioner (Local authority, Social Work Dept)
• Physiotherapy Services Manager (NHS Community Services Trust)
• Senior Community Physiotherapist (NHS Community Services Trust)
• Podiatry Service Manager (NHS Community Services Trust)
• General Practitioner

All of the interviews were tape-recorded and transcribed.Additionally, contemporaneous notes were taken during each of the groupinterviews. All the interviews were fully transcribed and prepared for analysisusing NUD*IST.

The Appendix to this report gives further details of the layand professional respondents.

The interview guides

The interview guides were developed in consultation with theproject’s steering group and, later, with the interviewers.

The interviews, themselves, were not intended to follow astructured format but to develop as issues were raised by respondents. Therewere, nevertheless, issues and topics which we hoped would be addressed in thecourse of the interviews. While a guide was provided, interviewers inevitablyadapted or developed questions which were comfortable for them and forrespondents, but covered the following areas:

• Background/individual information
• Perceptions of ageing and risk
• Experiences of falls

(The full interview guide is provided in Appendix A)

3.2 Phase 2: Data collection

The second phase of data collection was used to extendconcepts emerging from the first stage. The groups were selected to represent arange of social and personal settings and, in particular, which would allow usto explore specific issues from the first stage. The aim was to recruit olderpeople in the 60 to 75 year age group, although this was not always possible.In part, this was because the issue of falls (as we found in the first stage)was construed as a problem for the future and was not perceived to be a salientcurrent risk. We aimed to bring together groups of individuals who knew eachother, but who were not selected on the basis of their health status orexperiences of falls .

Contacts were made with a local community project inEdinburgh, and access to existing groups was negotiated via the project worker.Part of this involved discussion of how the research might benefitparticipants: it was agreed that we would return to discuss the findings and,in addition, would give each group a small fee which could be used for thegroup as a whole.

The five Edinburgh groups comprised an Asian elders (mostwere Punjabi or Urdu speakers); older people who were themselves carers;residents of a sheltered housing association; attendees at a two Day CareSocial Clubs.

Thus far, most data have been gathered in urban areas and itwas felt to be important to test the constructs on people living in rural orsemi-rural areas, to see whether there were differences of emphasis, meaningand salience. Five groups were convened in the Borders region. Again, we workedthrough existing groups and networks to bring together people involved in arange of largely social and leisure activities which included: members of abowls club; attendees of a fitness class; attendees of a community day centre;and participants of an over 60s club.

Characteristics of Phase 2 participants

A total of 50 people, of whom 40 were female, participatedin the focus groups. Twenty-nine (58%) were aged less than 75 years: only halfof the male participants were aged less than 75, but more than four-fifths(82%) of the female participants were in the younger age-group

The focusgroups

The first phase groups and interviews had been very general,in order to allow the range of individual experiences and perceptions toemerge. The second phase, however, was much more focused and explicitlyexplored a number of specific concepts and ideas around the definition,attribution and prevention of falls. In that sense, then, they could much moreaccurately be described as focus groups, whereas those conducted within thefirst phase groups were group interviews or discussions around a range oftopics. The focus for the second phase groups were quotes lifted directly fromphase one individual and group interviews. These were selected to exemplifyspecific constructs and participants were asked to reflect and comment on thequotes: did they think them to be "true"? If so or if not, in whatways; in what ways did they not match their own perceptions or beliefs?

Chapter 5 describes, in greater detail, how the two phasesof the study were linked, and Appendix B contains a full listing of all thequotes which were used.

3.3 Data analysis

The analysis of the data is being supported by a softwarepackage (NUD*IST). NUD*IST has a powerful cross-referencing and index facilitywhich facilitates in-depth analysis. Each interview was coded to reflect thebasic characteristics of respondents: whether they are lay or professional (andprofessional discipline); how they were recruited to the study; an assessment(based on the interviewers’ observations and self-report) of their current"fitness"; the type of interview (group or individual); and age-groupand sex. In addition, the narrative of each lay respondent and any narrativerelating specifically to them - whether within an individual or group interview- was brought together to allow analysis of individual cases, and of individualcharacteristics such as age or sex.

The analysis proceeded in four principal ways: first, eachdocument was coded according to a number of base characteristics, including itssource (lay or professional), by other features (such as whether it was atranscript of an ethnic minority or active lay group, or by professionaldiscipline), by age, gender and health of lay participants and so forth. Inthis way, it was possible to cross-reference any piece of narrative with thesebase codes.

Second, we identified key concepts which were felt to be atthe core of the research – for example, the definition, attribution, andprevention of falls by lay elders and professionals – and these wereposited as primary coding categories; second, using grounded approaches, thedata were read and re-read and narratives were coded.

Third, new coding categories were developed – either assub-categories of the core domains (e.g. "physical causes of falling"or "fear of falling" as sub-classifications of "Causes offalling" etc) – or as new dimensions arising from within the data asthey emerged (e.g. "Concepts of ageing", "Independence" andso on). Any piece of narrative could be coded in multiple ways, and could beplaced in any number of categories. Issues, themes, ideas were identified andexplored from within the data.

Finally, if an idea or concept appeared to be importantacross respondents - this was explored systematically using search facilitieswithin NUD*IST. For example – narratives relating to"independence" were quickly pulled together in this way. Similarly,at one point it appeared that the term "risk" was rarely used by layrespondents. NUD*IST’s Index Search facility allowed an exploration of whoused the term and in what contexts. In that particular instance, the searchrevealed that lay elders rarely used the term and, if they did, it merelyechoed the interviewer’s use of the word.

4. General constructions of falling

4.2 Defining a fall

The issue of what defines "a fall" at first seemedstrange to respondents, and the language used to talk about falls varied withterms such as "trip", "slip", "stumble" and"fall" being used. Respondents used terms to distinguish between howand in what circumstances falls occurred. Indeed, the distinctions made showedremarkable concordance with the clinical and epidemiological literature whichdistinguishes between externally caused falls and those which have aphysiological explanation. Lay and professional respondents expressed similarviews and used similar language to describe different falling events.

Resp M: As I said, I rose off the chair, but didn't know Ihad rose off the chair and I was found in the bathroom lying…
WHAT DO YOU MEAN WHEN YOU SAID YOU "DIDN'T KNOW YOU HADROSE OFF THE CHAIR?"
Resp M: Well, I must have rose off the chair.
Resp E: In other words the last thing you remember issitting on the chair (LayGroup2, Frail elders)

But if you stub your toe on something that could make youfall over to trip. But if you fall over it's through something affecting yourbalance. Turning too quickly you know. (LayGroup1, Active Males)

Well a fall to me you would have to go right down to call ita fall yes. (LayInt3, General Elder, Female)

Perhaps a trip or a stumble to me means nothing more thanthey have met with an obstacle! …If you stumble or trip you could saywell, "It was because I did this or that." Whereas sometimes if theyfall, the patient will say, "I don't know what happened. I just fell overand I woke up lying on the floor and I don't know why I fell."(ProfGroup1, Community Rehab)

Both professionals and lay respondents made cleardistinctions between different kinds of falling occurrences: those with anobvious or identifiable cause and those which were, apparently, without acause. Almost always, a "cause" which could be acknowledged referredto an external factor such as an uneven pavement or loose carpet. Those with anobvious external cause were "trips", whereas those without were"falls".

A trip is just tripping over something, over your feet, acrack in the pavement. I would consider that a trip. But a fall would be ablackout or just missing a step in a ladder, from a height. (LayInt5, Male)

You trip over something (LayGroup1, Active Males)

You would say, "I stumbled." A stumble doesn'tnecessarily mean a fall, it's a break in your regular movement, if you want toput it that way. WHEN YOU FALTER, WHAT'S A FALTER? That's the same thing. (LayGroup2, Frail elders)

One trips over something, but falls happen without obviouswarning.

You would fall if you’re not expecting to fall. But ifyou’re walking along somewhere which is pitted, things like that,you’d be careful when you are walking there….But, if you go into oneof these new plazas, you’re not expecting to fall and you’re walkingwith confidence along there…(Laygp1)

I wouldn't make anything of a trip. But thinking back now,the falls I can remember! I was walking in Gorgie Road a couple of years agoand I just went down. No reason for it, no trip because I looked after to seewhat did I trip on. And I didn't, I think it was the knee gave up and I justwent down. (LayInt2, General Elder, Female)

For some the defining characteristic of whether an incidentwas a fall or not, was whether an injury had been incurred.

Well, if you hurt yourself, like knocked your head forinstance or staved your arm, or like your husband hurt his. I mean you wouldthink, well that’s an accident. But, if you just staggered thatwouldn’t count. (Laygp3)

Well it would be bad if folk broke some bones wouldn't it?That would be very bad. I think a fall when you're able to get up after, wellthat's not too bad. But if you hit your head and you know cut it, I think thatwould make me really nervous. (LayInt2, General Elder, Female)

While "trips" or "stumbles" werefalterings in one’s step and had an external or environmental trigger, a"fall" was seen as something which happened without an obviousexternal cause.

You would say "I stumbled". A stumble doesn’tnecessarily mean a fall. It’s a break in your regular movement… Youfalter..that’s just slowing down, a stopping. A stumble is you’regoing with it…. And the thing is, you feel yourself going and you try tosave yourself because it's like a slow motion thing and you go stumble,stumble, stumble, and invariably you go down then….But the force of havingtripped over this pavement or stone or whatever it is has knocked you right offyour balance (Laygp2)

A trip's not so bad as a fall. A trip is not nearly so badas a fall. You regain your balance from a fall and tripping up steps, is not,of course they're carpeted and you're half way down there anyway. SO YOU CANREGAIN YOUR BALANCE FROM A TRIP? Oh yes. (LayGroup2, Frail elders)

Whereas a trip was an externally caused occurrence, a fallwas more often linked with poor physical health or extreme old age, and waslargely perceived to be explicable only in those terms.

I don't think people do fall. I think they fall as theresult of an infirmity of some kind. (LayGroup4, General Elders)

And as she walked away my mother turned around, she was 86and she had sort of slightly lost her balance. When she sat in the car she sortof sat like this. So anyway as she turned she just sort of toppled over….Yes I think so. I always remember that and how easily it was done, you know.She didn't have a big fall, she just sort of toppled over apparently(LayGroup4, General Elders)

The professionals made very similar distinctions betweenfalls with a physical cause, and trips with an external trigger.

You need to ascertain whether the person has actuallyfallen. How they feel themselves, how it's come about. Say for example ifsomeone was getting out of bed and they'd had a fall, maybe they were trying toget to the commode in the middle of the night or something; what they canremember about the fall, how the fall has actually come about. Whether theyfeel that they've had a dizzy turn or if they've slipped, you know, out of thebed. You know whether it was an environmental thing or whether it was aphysical thing… (ProfGP1)

Yes, probably if you stumble or trip it's explainable isn'tit. You couldn't have prevented it, it was just the corner of the pavement orsomething. You know something that anybody of any age could do. (ProfGroup1,Community Rehab)

Although the language and the precise terminology used totalk about falls was often variable and inconsistent with respondentsapparently using words like "trip", "stumble" and"fall" interchangeably, the language was neither neutral norinterchangeable . The distinctions drawn between tripping and falling emergedstrongly – not merely as one of definition: the two kinds of fallingevents had quite different meanings and implications for respondents.

Well one minute I was going along and the next minute I justfell all my length. There was nothing I could do to prevent me falling. HOW DIDIT HAPPEN? WHAT CAUSED YOU TO FALL?
Well that's what I'm saying, I don't know. That's what I'msaying, when I fall I don't know what I've fell over. I even went back to thepoint of where I fell to see if I had tripped over anything, and I haven'ttripped, well I can't see anything that I've tripped over, you know.(LayGroup2, Frail elders)

No. As I say, I'm just maybe walking along the road and allof a sudden I'm down. I don't even know why. The thing is that when I've felloutside, I've went back over my tracks to see if there was something there thatmaybe I did trip over but as my husband often says to me, "Put amatchstick down and you'll fall over it!" (LayGroup2, Frail elders)

Lay respondents would frequently start to talk about a"fall", but would invariably shift their language to talk of a"trip" or a "slip" rather than a fall:

Well when I got your letter I noticed it was geared tofalling and ….I mean I'm just as likely to fall, I suppose, if I don'tlook where I'm going. Or trip, whatever you want (LayInt5, Male)

Resp M: That's right. I fell coming down Pipe Street,just outside the housing office and I'm like that when I stumble I'm trying torun, but I'm bent so I can't get up again and so, down you go, and my kneeswere all grazed and that, but you can't stop yourself. Resp B: But thepavements are bad in Dundee. (LayGroup3, Active Females)

Well I did fall up at the bowling club once but that was awet a floor. It was slippy and it was a slight slope, it wasn't my own bowlingclub it was a different one, you know, playing away. But that was nothing to dowith age or knee or anything else, it was just a wet floor. (LayInt3,General Elder, Female)

I don't know what happened It was just, it was an unmadepavement. And I must have just tripped. I wasn't aware of tripping or anything,I was just aware of my face scraping the ground. (LayInt4, Active Female)

One respondent described a time that she was out with herdaughter and found herself on the ground. As she told the story, she said"Don’t ask me what happened", but then quickly goes on to excusethe fall to say that she had "just tripped..":

Now don't ask me yet, how this happened, the next minute Iwas lying on the shop floor and two or three young people came up to help me upand I said, 'Oh it's quite alright, I just tripped"…. Now the girlcame from the back of the counter and I said to her, 'How did I fall there?''Well,' she said, 'It's just one of these things,' she said, 'It's a slab wehave in there at that bit,' and it's about that much off the floor and ofcourse I tripped and down I went. (LayInt6, Frail, female)

All of these examples have in common an attempt by therespondents to find an explanation for the incident which would demonstratethat it was "just" a trip and not a fall. The last quote isparticularly relevant: in this account the respondent was anxious that thosewho had witnessed the incident would think she had "fallen" –and she also did not want her daughter (who was in another room) to know whathad happened. Although the respondent frames her narrative in terms of"not wanting to worry them", it was clear from her account that shefeared the consequences of their knowledge of the fall.

To my family because there's that bit in you, you don't wantto worry them, you don't want to worry them because anything wrong they're upin arms, and they're saying, 'What happened?' They're so anxious, you know tohelp…. I says, 'Look, I just want to get up.' I said, 'My daughter's downthe stair, I don't want her worried, I don't want her even to know.' (LayInt6,Frail, female)

In many cases the incident may well have had an externalcause, but the issue is not what did cause the fall or indeed whether itwas a trip, but the respondents’ need for it to have been caused bytripping over something. The avoidance of the word or the switch to other termssuggests that falls carry significant meaning for people. We suggest that thisis intrinsically linked with negative perceptions of "people whofall", and with individuals’ own need to maintain an identity whichis not construed solely in terms of socially stereotyped notions of older age.

4.3 What causes falls, what causes trips?

Both lay and professional respondents attributed falls andtrips to a range of factors which included physical factors which were felt tobe linked to the ageing process, environmental, social and psychologicalfactors. There was a clear propensity, linguistically, to link trips orstumbles with environmental factors, and falls with physical causes which theindividual had no control over – for example "blackouts".

Yes…. I worry all the time about falling but I can'thelp it. It's linked to my condition. (LayInt9, Asian, male)

My particular friend at home, her daughter's a nurse of somestanding and when she told her she said, "That's the second time thatshe's fallen, did she really stumble or was it mentally a blackout?"(LayGroup2)

I'll be honest, I had an operation in February of last year,I had a laser op for a cracked retina. I had a cataract op and put a patch onmy left eye and for a few weeks I felt light-headed when I turned quick. Ispoke to other people who'd had the same problem and they felt the same. Idon't know whether it's that or old age. (LayGroup1, Active Males)

The distinction between intrinsic and extrinsic attributionand between different kinds of falling events was echoed by the variousprofessional groups.

Well we would know obviously their medical history. So wewould have a rough idea of why, if it was just an accident they'd fallen orwhether it was something to do with their actual general health that had causedthe fall. (ProfGroup2, Chiropodists)

Well I haven't really looked at anybody under 65, but thepeople who we have looked at, say between 65 and 75, tend to have more of aproblem on a medical side, that you'll find they maybe have a neurologicalproblem, MS or some kind of Ataxic problem, Parkinson's. So there's seems to bemore medically related that they have a specific disease which will be cause ofthe fall versus somebody who's older would tend to generally be more frail.There might not be a specific disease that's being diagnosed causing fall. Itjust seems to be a more general problem. (ProfInt7, Physiotherapist)

An older person I think is more likely to stumble as aresult of some these other things that I've been talking about and then thestumble lead to a fall, you know. Younger people, I think, if they stumble aremaybe more likely to be able to regain their balance. If they trip oversomething certainly, they'll go down the same way as anybody would, young orold, but I think it's more likely to be as a result of some kind of externalfactor rather than an internal degeneration process. (ProfInt8, ChiropodistService Manager)

I wonder whether a fall could be more a medical conditioncaused by, like a sort of dizzy spell that the patient has no control over.There are no outside contributing factors, it's just a medical thing.(ProfGroup1, Community Rehab)

The "medical thing" was seen as thedefining characteristic or cause of a fall: respondents raised variousmedically defined problems which might cause falls – problems witheyesight and hearing, muscular- skeletal deterioration or illnesses (such asosteoporosis or arthritis), or other health problems which could account forfalling.

I fell, I went to the bathroom and I took a blackout, thewhole bathroom was blood splashed and my face was all black. The doctor thelast time I was in the hospital, he said, "You're taking fits, you won'tknow you're taking a fit," because you're unconscious. (LayGroup 2, L)

But the last fall I had was in the house and that was I'msure a blackout because I didn't even know I had moved off the chair….(LayGroup2, M)

The issue here, again, is not what the actual causes offalls were, or indeed whether lay elders’ and professionals’perceptions are "correct" or not. What seems to be important is theconstruction that older people put onto, what they regard to be, differentclasses of events. A diminished physical ability as a cause of falls was,largely, associated by respondents with frail old age or with an identifiableillness or disease process. It was rarely a characteristic that respondentsfelt applied to them.

I think what you've got to gear your thing at (i.e. theresearch) is to frail people and certainly infirm folk. They're more likelyto fall if they're in a wheelchair and things like that. And that's not a trip,that could quite easily happen. (LayInt5, Male)

There was a widespread perception, however, that balance wasimplicated in falls and trips:

But if you stub your toe on something that could make youfall over to trip. But if you fall over it's through something affecting yourbalance. Turning too quickly you know (Laygp1).

Lack of balance. It's black & white. People can toppleover for no particular reason other than just losing their balance. (LayGroup1,Active Males)

Changes in balance ability was perceived to be somethingthat not only may deteriorate with age, but was something thatrespondents were willing to acknowledge as a change which was, first,age-related and, second, affected them.

Well your co-ordination goes a bit. You over balance easier.Sometimes you turn to quick. (LayGroup1, Active Males)

You see we haven't got our balance, that's a thing thatgoes. We don't have such good balance as time goes by and when the bus jerksyou are more easily thrown ........(LayGroup2

What we mean is that we've not got a good balance, you know?(LayGroup2, Frail elders)

You know, I think also as you get older you're a bit morelight-headed. (LayGroup4, General Elders)

Well they haven’t got the same balance. I know Ihaven’t got the same balance because of this foot again. For a long whilethere I couldn’t turn quickly. (LayInt1, Frail Elder)

Well their balance is not as good as what it is when they'reyounger, for one thing. And then, well in my case sometimes it's not so easy toreach up because of joints and what have you, that are not so flexible as whatthey are when you are younger. (LayInt4, Active Female)

The lady who should have been here instead of me, she's hada few falls, she unfortunately couldn't come and she had a very bad onerecently, when she was thrown up the bus. You see we haven't got our balance,that's a thing that goes. We don't have such good balance as time goes by andwhen the bus jerks you are more easily thrown (LayGroup2, Frail elders).

The professional perspective was very similar, but was stillcharacterised by uncertainty about the actual processes involved:

Balance actually deteriorates as you get older. The tissuesbegin to tighten up, the centres in the brain that respond to movement becomeless sensitive, therefore you can be unbalanced, correct me if I'm wrong. Youcan become unbalanced!! More easily. (ProfGroup1, Community Rehab)

With high blood pressure when you stand up, well standing upand continuing to walk, it's when you stand up and you're off balance and yourfeet are all over the place. (ProfGroup2, Chiropodists)

For some reason they lose their balance or they overbalance.....Because they can't stop themselves. They lose their balance and just landwith all their weight on whatever part of the body. (ProfGroup3, CommunityNurses)

Yeah, I would say it's to do with a loss of balance ororientation which has the end result of the individual lying in a prone state.(ProfInt8, Chiropodist Service Manager)

Well they're becoming frailer, therefore they're losing someof their motor ability, balance ....... of old age, failing sight, failinghearing, which are all things which would help anybody avoid risks and doingdamage to themselves. (ProfInt2, Home Care Services Manager)

A number of respondents speculated about how trips ratherthan falls happen, and whether there was any factor which was age-related.Again, balance was the factor most readily mentioned.

You're just not able to hold a steady position, or walksteadily. Definitely, balance is quite an important thing as you get older. WHYDOES BALANCE GO?
Well I don't know why balance goes. Whether it's somethingin your head or partly whether it's muscular, that you're ..., well with me,it's partly ankles that are weak and they'll go LayGRoup2)

Resp M: They say you lose a lot of your balance as you getolder.
Resp C: Oh, yes, they say you do, you definitely do. I find that.(LayGroup3, Active Females)

Well yes I think so. I don't know why. I suppose you maybeget a wee bit unsteady. I haven't quite reached that yet! But I have known offriends who have fallen. And I suppose because of that I'm more careful myself.(LayInt3, General Elder, Female)

Problems with feet and difficulties with gait were alsomentioned by lay and professional respondents as a factor in trips or stumbles:

I don't think you, well this is personally, you don't liftyour feet off the ground properly so you stub, you're inclined to stub yourtoes. I have weak ankles and I can go over on a crack shall we say, but I thinkoften now I think, probably I give myself a row and say, "You're notlifting your feet high enough off the ground," and that'll probably be allmuscley won't it? That you are not using, you're not lifting your feet, soyou're stumbling and down you go.(LayGroup2, Frail elders)

I think as the lady says, I think we just don't really liftour feet high enough, you know. (LayGroup2, Frail elders)

Now in that floor they had linoleum, but they had itsticking up about that. Well you know as the legs get on, I suppose they mustbe walking nearer the ground, I used to lift them you see, and of course Itripped on this thing and down I went. (LayInt6, Frail, female)

Some felt that they were less flexible and had less strengthand, although these were not seen as causes of falls, these problems wereregarded as contributory factors in trips.

Once you start to trip you can’t straighten yourself intime, you just go down. There's nothing to hold on to. (LAYGP3)

Well, you would balance on an uneven pavement, but we don'twe go down, because or your age…You can't straighten up quick enough andgo right down. (LayGroup3, Active Females)

Resp M: I think you do get a bit frustrated with your body.Going up on stepping stools and up ladders and I'm not as quick, and when I getup to the top of the ladder, the one I've got is quite high, I've got to steadymyself.
Resp G: It's this thing that in your mind you're doing itand you feel that you can do it in your mind, but your body reminds you.(LayGroup4, General Elders)

Although respondents might acknowledge that balance(including their own sense of balance) may deteriorate with age there was stilla tendency to regard the cause of trips and stumbles as unrelated to age:

That's a judgement thing, but I think that could happen toalmost anybody, couldn't it? (LayGroup2, Frail elders)

The salient factor in relation to "trips" or"stumbles" was that, not only were they perceived to have anidentifiable external cause, but also that they were something that couldhappen to anyone – regardless of their age.

She tripped in a very innocent situation, she tripped overon the pavement. (LayGroup1, Active Males)

Well, silly little things. I mean in one, who broke herpelvis, she was just hanging her washing out but she stood on wet leaves in thegarden. So simple. (LayInt3, General Elder, Female)

Not only might these event occur in "simple" or"innocent" ways, age was not perceived to be a key factor:

But I don't think people fall just because they're older.(LayGroup4, General Elders)

Uneven surfaces are one of the things I would say mostpeople trip over. Not just elderly people but most people (LayGroup1

No about ten years ago. No more than that, I would say itwas about 1976, so twenty years ago. But that was not anything to do with ageor anything like that. It's got to do with stupidity I didn't know that thepavements were higher there, you know. (LayGroup4, General Elders)

Yes, probably if you stumble or trip it's explainable isn'tit. You couldn't have prevented it, it was just the corner of the pavement orsomething. You know something that anybody of any age could do (ProfGroup1,Community Rehab)

Trips and stumbles happen in every day life…(ProfInt3,General Practitioner)

Well yeah. Just as F was saying, you know, sometimes peoplefall over, I don't mean it's….something that I could have done. I didn'thave to be frail or elderly, so it was a fault perhaps with the actual pavementor there was something in my path that I hadn't seen. And you know I could havebeen any age and tripped over something. So I suppose in that way it's moremaybe explainable, it wasn't a physical reason, that there was something wrongwith me so I fell, it was more environmental. (ProfGroup1, Community Rehab)

The impact of a fall or trip was, however, seen to begreater for older people:

I tell you do, you're more inclined to hurt yourself as youget older, I mean if you trip - well for instance at the holiday's remember,now I tripped and broke my wrist and that was just being with the family, butit was my own fault - I was talking to them and just a step like that and Ijust walked forward and I fell. And I think that's quite a common thing really.But I think if you do fall you are more liable to hurt yourself when you'reolder. (LayGroup3, Active Females)

Well it was a combination of both. The damage obviously wascaused by her age because normally when you're younger and you fall, you pickyourself up and that's the end of the story. But obviously, especially women,suffer from osteoporosis which means that the consequences of a fall are quiteserious. (LayGroup1, Active Males)

Professionals raised osteoporosis as an importantconsideration in their assessments of an older person:

Because if you trip, especially if it's an osteoporosispatient, the trip would be likely to damage or cause more fractures trying tosave themselves. (ProfGroup2, Chiropodists)

With an elderly person there's the added factors of possiblyosteoporosis, osteoarthritis, all of the things that we normally associate witholder people, that can make injury more ..., make people more susceptible toinjury, so their injuries from a fall may be worse because of their underlyingconditions. (ProfInt6, Physiotherapist)

There was awareness – particularly among the women– of the impact of osteoporosis and its implication in falls. The linksbetween disease processes such as osteoporosis and the hormonal changes of themenopause did seem to be both known about and understood and was seen as anage-related problem.

Oh I think so. I think because we do, our bones get thinner,there's no doubt about it. They call it osteoporosis, brittle bones, and yourbones do get thinner, you know. And they're harder to heal then. So you've gotthe problem, a break and then arthritis sets in. I mean we know all the termsof it, the way it works, you know. But it's just things that happen with oldage. (LayInt1, Frail Elder)

My mother was a bit, see in these days you would have said'What's that? What's osteoporosis?' (LayGroup4, General Elders)

For one respondent, concern about osteoporosis had promptedpreventive action.

Well about five years ago I went on HRT because I wasconcerned about osteoporosis, I was really concerned about that because I'd hada friend that had a bad fall, I'm sure that was what it was with her becauseshe was only fifty at the time and I thought, right, ..., and the curling gaveme a fright, that fall I had at the curling and I thought I was very luckythere, I think I'm going to go on HRT. (LayGroup4, General Elders)

Those who lived alone were more likely to express concernsabout falling. Living alone was not seen as a cause of falls per se, but thoseon their own were conscious of the absence of help with everyday tasks whichmight involve reaching up or climbing. The greater concern, however, was thatthere may be no-one to find them if they did fall and no-one to care for themif they were injured.

Because there is nobody to look after you. You know you'vegot to keep well if you can. And you've got to be very careful and I think thatsort of puts you on the alert. When you're young you sort of dash here and dashthere and don't stop to think, but you do know the dangers. (LayGroup4, GeneralElders)

I think you find if you're young it's not a problem if youhave a fall because you've got someone to look after you, but as you get older,you don't always have that, you know, you're more often than not on your own,or maybe with somebody that is infirm. You just don't know. (LayGroup4, GeneralElders)

Some participants – especially those who had tripped orfallen – felt their confidence had been dented. The notion that fear offalling itself might be a cause of falls was not explicitly mentioned: on thecontrary, there was a view that over-confidence may contribute to falls.

I think just being more cautious. I think that it wouldn'tdo to be thinking about it all the time, you know, I'm going to fall. Iremember going out on a frosty day a few years ago and thinking to myself, I'mvery good on my feet, I hardly ever fall. And down I went! That same day. Inever think of it, so it doesn't do to be always too cautious. (LayInt2,General Elder, Female)

4.4 Who falls? Who trips?

Fallers – people who fall, but not the respondents– were perceived as old and frail.

Yeah, older people I would think, just peoplewho are ill. Poor Mr M next door he has Parkinson's disease, so he can't evergo out without someone, in case he falls because he doesn't feel confident forwalking. I suppose there's other illnesses as well which would make you feelless confident. (LayInt2, General Elder, Female)

Age and frailty were negatively perceived, andeven those in our sample who might be easily defined as old and frail did notassociate these images with themselves.

Well I suppose as you get older, you get lesssteady on your feet. I'm only assuming because I'm still quite steady most ofthe time. Yeah, people get frail don't they? As they get older. (LayInt3,General Elder, Female)

That's the point about our approach to life -we're not old. These people who fall are old. (LayGroup1, Active Males)

And, among the same group of "active males":

It's a question of outlook, I was at hospitalyesterday seeing the doctor and I was in the Out-Patients Department and allthese people are old - and they really were! That I think sums up, that somepoor old souls, they're were probably the same age or younger some of them.(LayGroup1, Active Males)

No, I don't think there is a set image. It couldhappen to anybody really. (LayGroup3, Active Females)

The generally negative image of "the faller" wasreinforced by a perception that fallers may also be drunk[s].

The people who fell outside their houses weremostly older women actually, who got out of bed or had a heart attack orsomething, fallen on the stairs or over their shoes, but as I say the onesoutside were always drunk! (LayGroup1, Active Males)

I think if I saw anybody fall I would help him.In fact we were coming up fae the swimming one morning and this was between tenand eleven and there was a man lying on the pavement across the road, on theLochee Road, so, it was Davy Shaw that was with me at the time, we went acrossto see what was happening. He was dead drunk, at that time in the morning!(LayGroup1, Active Males)

That's how my husband feels since theParkinson's started. He feels as if he's walking like a drunk man, and he'snot! (LayGroup4, General Elders)

While most people, who had not experienced what they wouldcall a fall, did not regard themselves as old or frail there was a consistentview that disorders of balance or illnesses affecting balance (includingmedication) were a factor in falls. It is noteworthy, nevertheless, that theseexplanations often related to other people and not to the respondent, andimplied that balance was impaired because of an underlying pathology orillness.

Well my mother had the raised blood pressure andI think maybe that affected her. (LayGroup4, General Elders)

Oh aye. Well they get it through ear trouble andso forth you know, the balance can go. I used to take a lady down the road,she's only a few doors down from me, and she was so scared because she said herbalance was away. (LayInt1, Frail Elder)

The professionals also distinguished between those withspecific health problems or who were simply old and frail and those who had"merely" tripped:

Certainly a lot of our clients that have hadstrokes seem to be quite at risk of falls. People with any sort of muscularweakness of degeneration. I have quite a lot of clients that have got, welleither like, multiple sclerosis or a degenerative neurological condition andthey seem to be ones that we get the referrals for falls. Also I suppose anysort of balance problems. A lot of our clients with rheumatoid arthritis, wheretheir, particularly on their feet and their knees, tend to be referrals thathave fallen and people with, I don't know if people with osteoporosis fallmore, but they tend to brake more bones, so we get more referrals from peoplewith osteoporosis that have damaged their bones as a result of a fall…. Wealso get quite a lot of referrals for people that have epilepsy who are fallingfrequently and they would be the young age group, you know, quite involved insafety aspects - not to stop them fall, but to stop them doing as much damagewhen they fall. So we get quite a lot of referrals from people with epilepsy.(ProfInt5, Occupational Therapist)

Now the reasons why their perception might bechanged could be because of a clinical disease but most likely it's the ageing,the slow messages that are going up and the fact that even if they get amessage they are not able to quickly change because their muscles are weaker ortheir joints maybe less flexible. (ProfInt3, General Practitioner)

Yes, I mean, yes, I think when we're talkingabout older people you immediately think of their physical ability and how ablethey are to, what their mobility is really. And if it's limited in some way,then I think that causes, that's a risk of falling, that would cause a risk offalling. (ProfInt1, Care & Repair Manager)

4.5 Perceptions of self as a faller or potential faller

Apart from those were particularly frail and had a historyof falls and, although most could relate a falling-type incident, there was aview among respondents that falling was, at best, only a distant future risk.Some had made changes which might be regarded as preventive or precautionary,but the prevailing attitude was one of continuing to live ones’ life fullyas before.

I think, I'm not saying I would be like that inten years time, but I think because I've always been very, very fit, I felt Icould cope with it. (LayGroup4, General Elders)

I don't think about it but mind you I takeprecautions in the house that I wouldn't have done ten years ago….I put a shower cabinet in because I think it's safer with a shower cabinetthan what it was with the bath. When you're on your own you can slip in a bathand there's nobody there. Wee thing's like that. (LayGroup3, Active Females)

I think just being more cautious. I think thatit wouldn't do to be thinking about it all the time, you know, I'm going tofall. I remember going out on a frosty day a few years ago and thinking tomyself, I'm very good on my feet, I hardly ever fall. And down I went! Thatsame day. I never think of it, so it doesn't do to be always too cautious.(LayInt2, General Elder, Female)

It was also apparent, despite an unwillingness to regardoneself as a potential faller, that some had made subtle changes in theiractivities because of their perception of the chances of an accident.

But I've never liked climbing ladders,step-ladders or anything like that, so I just don't do it. If I need a lightbulb changed I wait for one of my daughters to come in! I just don't. That's mebeing ultra-cautious! I mean if I was to fall there's nobody here to pick me upso you have to be more careful. (LayInt3, General Elder, Female)

Some said they would consider making significant changes– such as moving house to a "safer" environment – or moreaccurately a "smaller" house – but were aware of the emotional,physical and financial upheaval this might involve.

Resp M: But then again they speak airy-fairyabout saying, "Well, move to another house," but if you move intoanother house the older furniture you have and everything doesnae fit in and itcost you. And it's a big upheaval.
Resp B1: It costs you money because you cannae ....
Resp B2: And there's leaving a lot of friends, neighbours and things.
Resp U: That's a good point B.
Resp M: You could go some place where it's all young people or that.
Resp A: You move away and you've no friends or good neighbours.
Resp U: Being contented where you are makes a big difference. (LayGroup3,Active Females)

The term "risk" was rarely used spontaneously byrespondents. Indeed, he word itself was almost wholly used only in response toa question from the interviewer which included the word. For example:

SO DO YOU FEEL YOU ARE AT RISK OF FALLING?
Resp B1: I don't feel at risk.
Resp B2: I don't think about it but mind you I take precautions in the housethat I wouldn't have done ten years ago. (LayGroup3, Active Females)

Rather, the language of risk is more complex and highlycontextualised. The older people in this study talk about "not takingchances" or "being careful": they did not talk about risk perse.

…you don't bother going and getting thesteps you just stand on a chair or a stool. I do that all the time. You know,we should really, I suppose be more careful in doing things like that. If myhusband wasn't in and I wanted to clean the lamp shades, I just go and do themmyself. (LayInt2, General Elder, Female)

I think at home, though, you're so used to doingthings, you don't realise that you're not so able to do things – you climbup on a chair instead of maybe getting… (LayGroup3, Active Females)

What these respondents are describing is how one continueswith everyday activities as usual and the notion that there may have beenage-related bodily changes which make this now "risky" (or riskier)is not necessarily to the forefront. Instead, what a number of respondentsdescribed was the slow process of adjustment to bodily changes.

I find that now, I used to just nip up thesteps. I've got a big hedge at the side of my house and I've got to trim it andnow I get my next door neighbour to do it. And I've seen the day when I wouldnever ask my next door neighbour to cut the hedge, but it means going upladders doing that. I don't do that now. And even five years ago I would havebeen quite happy to say, "I'll do it." (LayGroup1, Active Males)

Resp B: Yes, I'm beginning to feel that. When Icome to the shop's now, when I come to a ridged walk I'm not so confident as Iused to be.
Resp C: Yes, I used to just stride along, but I don't now. (LayGroup3, ActiveFemales)

No seriously, until there comes a point in time,where obviously I know things do change.
BUT NONE OF YOU HAVE ACTUALLY CHANGED?
I feel exactly the same person. Resp J: I've slowed up a wee bit since Ihad the blood clots. People say to me, "Gi'e up your allotment," butI'm not because I enjoy it and it takes me a wee bit of work, but I do it. I doit organically, you know, I dinnae dae a lot of digging. If there's anydigging, I'd pay a lad to do it. (LayGroup1, Active Males)

Resp C: I don't know about others, but I findthat if I turn too quickly, you bump into things quicker than you used to, youdon't seem to judge - I'm always bumping into a door or a stool.
Resp B: Is it your eyes?
Resp C: I don't think so really, because I can see better than I can hear - Iwould think it's just that I turn too quickly for my age. (LayGroup3, ActiveFemales)

The older person as a "risk-taker" was, however,evident. One respondent in particular – a frail women who had a history offalls – had a perspective which, although somewhat extreme, exemplified adetermination not to modify behaviour to minimise risk.

Resp L: Yes, I've been told that I've not tostretch, not to climb because I climbed ..., I got murder for this. I climbedup on top of the table to water my plants, and I fell and broke my ankle!(LAUGHTER) It was my own fault.
HOW LONG AGO WAS THIS L?
Two years ago.
TWO YEARS AGO YOU CLIMBED ON TOP OF A TABLE TO WATER A PLANT, BUT YOU'VE BEENTOLD NOT TO DO THINGS LIKE THIS?
I've been right told! (LAUGHTER)
SO WHY DID YOU DO IT?
Because I wanted to do it, ken, I like doing things for myself.
SO YOU KNEW THERE WAS A RISK BUT YOU DID IT ANYWAY?
I was very careful getting onto it. I got a pouffe and I stood on the pouffe,leant on the table, then I got one leg up and of course my other leg's gammy,and then because the table slipped back ....

When pushed by others in the group, she remained defiantlyadamant that she would continue such stunts – regardless of the risks ofan accident and, indeed, denied that there was any "risk".

DID YOU KNOW THERE WAS A RISK IN WHAT YOU WEREDOING?
Resp L: No, but I'm that kind of person. I would try it.
Resp E: Why do you want to have the plant up there?
Resp L: Because I just want it.
Resp E: But that's not enough reason though.
Resp L: Oh aye it is.
Resp E: No, no. No, no. Just wanting things isn't ....
Resp L: I've still got the spirit to live. (LayGroup2, Frail elders)

Perceptions of personal risk in relation to falling wereclosely linked to perceptions of self as either old or frail. Asian elders whoparticipated in the study were, as a group clearly very much affected by fearsfor their own safety and made efforts to eliminate any overt risks – notmerely by changing their behaviour, but by ensuring that someone else did thosetasks they regarded as "risky".

I don't do anything strenuous. I have also beenasked by doctor to take things easy. So I avoid all risky things. Like, I evendepend upon the Centre transport bringing me here. I don't drive now, don'ttake buses. I walk to the shops through good pavement area even though it'slonger walk to (Community Centre) and I do only necessary shopping not to carrytoo much, so I avoid all strain (LAYGP5)

I became very, very careful after I tripped andfell in the house. Since that day I have become very careful not to leavethings lying around and I also usually try not to go out alone too much andavoid walking on bad pavements in the evening and in winter when it gets darkmuch quickly. (LAYGP5)

The Asian elders seemed more ready than the others we spoketo, to define themselves as both "old" and "ill". Those weinterviewed were perhaps a little older than other respondents, but notmarkedly so and the data do suggest a rather different approach to ageing. Theethnic minority elders seemed to be not only more dependent but also morewilling to be dependent. Asian elders, traditionally, would have lived withadult children and would not have been expected to fend for themselves in oldage. To some extent, that pattern has altered, and a number of those weinterviewed did live on their own in somewhat restricted environments and withsomewhat limited lifestyles.

When I first fell, it was shocking and verydisturbing, but it was expected, because after the stroke I had lost my balancequite a lot and the doctors had also warned us. (LayInt9, Asian, male)

Yes, I can say I am at risk of falling because Iam not fit health wise. (LayInt7, Asian, female)

4.6 Can falls be prevented?

There were often contradictory views expressed about thepreventability of falls. On the one hand, those who had experienced falls whichthey regarded as condition-linked could see no scope for the prevention oftheir falls:

There's nothing really I can change aboutfalling. It's just one of these things that suddenly happens and that's allthat I feel. (LayGroup2, Frail elders)

Resp C: Oh no I don't think so. Do you thinkanybody could help you not fall, I don't know.
Resp M: No, if it's going to happen it'll happen. You just go down. Just sheeraccidents. (LayGroup3, Active Females)

On the other hand, those who had not experienced such a"fall" – were more optimistic, and felt there were bothenvironmental and personal behavioural changes which might prevent or minimisefalling. Again, it is noteworthy that change is advocated for others ratherthan being seen as being of current relevance for the speaker:

Education of footwear, education about authorityto make better footpaths. Keep them all on one level as much as possible. Inhouses as well as ... (LayGroup1, Active Males)

I think a shower, quite frankly, I mean I canunderstand how you feel about baths but I think a shower is safer as you getolder, than a bath because you don't have to step in and it's easier to getout. The one I put in, as the girls will know, I put in for the benefit of myhusband, it's just a wee step that's manageable…. Yes my husband couldn'tget out ... But I think that's a thing that elderly people, older people dofind that showers are safer as time goes on. (LayGroup3, Active Females)

And, in response to a question about behavioural change inolder age:

DO YOU THINK OLDER PEOPLE IN GENERAL THEN CHANGETHE WAY THEY BEHAVE OR WHAT THEY DO?
It depends on their health condition does it not? (LayGroup3, Active Females)

Professionals too made the distinction between physical,age-related and environmental aspects of prevention and regarded their role aslimited to the physical causes of falling:

If they're just trips then they're more likelyto save themselves, but if it's blood pressure or something then they just godown or faint, whatever, they can't save themselves. (ProfGroup2, Chiropodists)

Trips and stumbles happen in every day life andtherefore they are not a professional problem necessarily - they may contributeto the history but just because somebody trips would not be a reason to call aprofessional. (ProfInt3, General Practitioner)

Respondents who lived on their own were perhaps moreinclined to caution, and there was awareness of economic factors which affectedsafety:

But I've never liked climbing ladders,step-ladders or anything like that, so I just don't do it. If I need a lightbulb changed I wait for one of my daughters to come in! I just don't. That's mebeing ultra-cautious! I mean if I was to fall there's nobody here to pick me upso you have to be more careful. (LayInt3, General Elder, Female)

We're all lucky we have 'phones. But money-wiseand everything else, I think when they were doing the Sheltered Housing andthat, that's one of the things they should have done. Put a 'phone in folk'shouses. (LayGroup3, Active Females)

Nevertheless, people were anxious to present examples whichshowed that falling was not an inevitable consequence of an ageing body:

SO FALLING IS NOT SOMETHING THAT'S CONFINED TOTHE OLDER PERSON THEN?
No I don't think so. I think young people are just as likely to fall throughdrink, drugs. (LayInt5, Male)

No. My father is 86 and he's never fallen in hislife. U: He's marvellous. J: Neither did my mother, she was 73 when she diedand she had never fallen. (LayGroup4, General Elders)

4.7 Getting older, being old

Perhaps inevitably, an older person is always going to besomeone older than oneself and it was quite clear that few of the respondentsregarded themselves as old. Being old implied frailty, dependence, weakness,inactivity, and falling.

A number contrasted themselves with their parent’sgeneration.

They were old at 52 or 53. (ALL AGREED) But then when youthink about the lifestyle of these people who lived through real hunger andreal poverty and the work conditions that they worked under, where they wentout at 6 O'clock in the morning and didn't come out until 6 O'clock at nightand went straight home to their washing and having to bring up children. Theirlifestyle was completely different to what it is today where I think, when Ilook back now that they were old when they were fifty, (ALL AGREED) and atsixty and they were poor, poor souls and you saw them falling and being old.(LayGroup1, Active Males)

There was a marked tendency to compare oneself with others,who were frequently perceived as having an "old outlook".

It's a question of outlook, I was at hospital yesterdayseeing the doctor and I was in the Out-Patients Department and all these peopleare old - and they really were! That I think sums up, that some poor old souls,they're were probably the same age or younger some of them. (LayGroup1, ActiveMales)

I know because in the club I see some poor souls. I meanthey're all away the day, this day that you’re here, but they're all awayon the barge the day, but there's some poor souls…. (LayInt6, Frail,female)

One physically frail respondent also seized on the"oldness" of others which was characterised by acting out stereotypesof old age.

I mean I've got a friend, he's coming up for sixty one andhe's in sheltered accommodation, he goes about with, well I say old people! Hegoes to all these things and I told him, "You're old before yourtime!" But he considers himself, sixty one, he's not even on a pension yetand he's just stopped and threw the sponge in. (LayGroup1, Active Males)

There are two folk beside me that bore me to tears becauseall they talk about is their bills. They're going to end up dead. (LayGroup2,Frail elders)

I think what you have to remember is that people fall todayas a result of extended life span…I mean a century ago if they reachedsixty they were old. But because of modern science and technology, our lifespans have all been extended, so that's why they're falling. It's not justbecause they're old, it's because they've got all these other littleinfirmities that are coming along with them. (LayGroup4, General Elders)

Respondents were scornful of others’ perceptions ofthem as "old", and they had much to say on what "old" was.While much of this was rather cliché-ridden (you’re as old as youfeel etc), much represents a real insight into emotional, psychological andphysical dimensions of ageing in the late 20^th Century.

It's a mistake of younger people to think that somehow oranother that when you're old you're different, you're a different species. Youremain exactly the same person, all your life. You're surprised that they don'task you to play in the first football team and things like that! (LayGroup1,Active Males)

Resp C: It doesnae say, "Young," it says,"Young at heart."
Resp U: Yes, it's how you feel.
Resp C: I mean some young people feel old. Act old.
Resp M: Some of them are born old. (LayGroup3, ActiveFemales)

Resp M: So he gave me an injection and that wasn't too badyou know, and it eased it a wee bit. So he 'phoned up the Infirmary and it wasthe first time I've ever heard myself described as 'elderly.' (LAUGHTER)
Resp U: It comes as a shock doesn't it! Resp M: 'Now I have a patient, an elderly patient.'(LAUGHTER)
Resp U: That hurt you more than your shoulder.
Resp M: I thought what a damn cheek! (LayGroup4, GeneralElders)

Others talked about a mismatch between what they thoughtthey could do and what they could actually do and this, in turn, was linked byrespondents to their self perception as not old. The importance of"keeping active" was a recurrent theme in these narratives for bothmen and women.

I mean I think I can speak for all the people I know here.We have always been active and we still continue to be active and we find asthe years go on we're not quite so able to do the things we did before and ittakes a little time adjusting to that and that's why. I think so. (LayGroup3,Active Females)

The discussion among the women continued:

Resp E: It's difficult to generalise because these folk thathave never done any exercise will be old before their time.
Resp B: Most of us have been active all our days.
Resp C1: I don't know about C2 because we didn't know herwhen she was young, but we've always been active. (LayGroup3, Active Females)

The male respondents also regarded physical activity to beimportant:

Resp J1: I think if you sit around the house your morelikely to fall. You've got to keep yourself active.
Resp J2: Oh yes, I think as long as your active your blood'sstill circulating the way it should be and when you stop being active
Resp D:You really think of yourself as being young, until somebody tells you you'reold. (LayGroup1, Active Males)

A person thinking about old age, it's all relevant to whatthey do themselves. If you're active, you don't think about old age. So, ifyou're sitting around saying, "Oh I cannae do this and I cannae dothat," then you start thinking you're old. (LayGroup1, Active Males)

Although respondents often talked about "feelingyoung" or "not feeling old" as a state of mind, bodily andphysical change had a way of dominating:

Resp G: I mean I think I've got boundless energy now...
Resp U: So you have.
Resp G: Yeah, but I haven't. I mean I go to bed knackered!(LAUGHTER) And I mean the next day I have to pace myself where as years ago Ididn't have to pace myself. I still do a lot for my age, the next day, but I'maware of it. You know, I'm having to force myself at time, saying, 'Oh I reallycan't be bothered to do this,' and I'm saying, 'Do it, you've got to do it, soget on and do it,' you know. Whereas years ago you don't even think about that,you just do it, automatically. (LayGroup4, General Elders)

Resp M: And I think you don't get older in your head - it'syour body that doesn't react the same. I think there's that, that you don'tfeel any different, but you get a shock when you look in the mirror!
Resp J: Agreed. But you don't feel old.
Resp U: No not 'till you look in a mirror and you think goodgrief!
Resp J: I get a fright when I see my reflection in a mirror in a shopand I say, 'Who's that old woman?'
Resp U: You don't believe it. (LayGroup4, General Elders)

SO WHEN YOU HAVE AN IMAGE OF AN OLD PERSON IN YOUR HEAD,WHAT'S THAT IMAGE? Well, I was going to say somebody with a walking stick, butthen I use a walking stick myself sometimes! When my knee's bad. But not as ageneral rule. If I was going to look round gardens or a park or something andknew I was going to be on my feet a while. Well it's not a walking stick it's ashooting stick. I kid myself a bit you see. But I take that along with me, andif you stop to admire something you've got something to lean on, that's all.(LayInt3, General Elder, Female)

Resp G: You know, that's how I try to put it intoperspective. I try not to think of getting old, I just think well, I'm still alot luckier than somebody else who's got lots of problems, you know.
[All: Agreed.]
Resp M: But I know the difference because I was sixty twowhen my husband died. Now three weeks after he died, I looked at the house I'min now and decided that I would make the move, and within eight weeks I hadmoved into the new house. Now, I had an awful lot to do because it was a bighouse..[ ] And I don't know if I could tackle all that now. I mean it's thedifference in the fourteen years. (LayGroup4, General Elders)

This shift in self-perception may not occur until there isan event which brings physical limitations into focus. One respondent talkedabout her concern that she would not be able to hold her new grandchild, andhow this had made her feel for the first time that she might be old. She didnot feel "old" but felt limited physically by age:

So on rare occasions I perhaps admit to myself, but it's adifference to admitting you are old and feeling old, right? I don't, you feelyou're not able to do things, but you're not saying to yourself, 'Oh I can't dothat any more because I'm old." It's a refusal to believe!! Pushing theevil day off far away. LAUGHTER I can't answer that very well. I suppose thereare sometimes yes when I do feel it. This has got nothing to do with the talkbut I'm going to become a grandmother in August for the first time and my firstthought was oh dear, I'll not be able to do anything for this babe. I won't beable to take it swimming or take it walks or anything because I know, I meanpeople say, "Oh but it's lovely" And I say this quite jokingly, but Iknow myself I will not be able to lift this child because my wrists aregetting, you know, sometimes they're painful and this neck and back thing. Iwould be able to lift a wee baby but the things that one would like to or wantto have done, I'll not be able to be the help. So I'll just have to hope thatit's not really necessary for me to be helpful in that sense, that they don'tneed me physically. I'll be able to hold little babies and things but I'll notbe able to do any of the really physical things because holding infants andlittle ones when they get to toddler stages - they're quite heavy. (LayGroup2,Frail elders)

The professional perspectives of ageing were not so verydifferent from those of lay respondents, but were perhaps more inclined (oftendespite their best intentions) to be influenced by actual age rather than byfunctional ability.

I think it's just something, it's just all to do with age,you know. You're a certain age so you must be frail and not able. Which in ourexperience here is not the case because we meet people in their nineties whoare actually really quite able and can do lots of things and are amazinglyindependent or whatever, you know. (ProfInt1, Care & Repair Manager)

4.8 Being and remaining independent

Being and remaining independent was an all-important goalfor most of the men and women we spoke to. There were exceptions: some were andregarded themselves as dependent because of a physical condition or frailty.But, by no means did all those who were frail see themselves in this way. Itwould not be appropriate to generalise too far at this stage and, as we noted,Asian elders were somewhat older and frailer than other participants. However,as a group, these respondents were perhaps more willing to define themselves as"frail" and as hence "dependent", and this possiblycultural difference was noteworthy:

I also depend upon my husband and children for many thingsbut I still do most household things myself even though I am very weak and feelvery tired often. But of course I am not as active as I was when I was younger.(LayGroup5, Asian Elders)

Resp A: My confidence in doing things went down after myhusband's death and then my arthritis, both have made me feel very dependentand very weak.
Resp B: That's like me, after my wife died and after myheart attack 3 years ago all my confidence just went, now I am a very weak anddependent person as well. (LayGroup5, Asian Elders)

Others, however, asserted their independence and theirdesire to remain so, and discussed the part that a fall might play inundermining their independence.

I think that business about independence is a definitething. You've got to try and work and be as independent as you can. AND WHY ISTHAT SO IMPORTANT? Because you don't know. I mean you must limit yourself towhat you yourself can do. There's not always going to be somebody there to helpyou. (LayGroup4, General Elders)

We don't want to lose our independence, as much as we loveour family and they're there. And they would all take us on I'm quite sure, butwe want to have our independence and maybe subconsciously we're taking morecare of ourselves. (LayGroup4, General Elders)

Yeah, well as long as we can. It's the best thing to doisn't it? Or you'd be dependent on other people all the time. (LayInt2, GeneralElder, Female)

I think if you've been independent all your life, it's anembarrassment to be dependent, I think. (LayGroup1, Active Males)

Respondents were aware of the possible conflict betweensafety and independence, and represented a personal struggle: at what pointwould or does independence become compromised by the bodily constraints ofageing? To some, even making changes within their home can represent a loss ofindependence, an acknowledgement of ageing.

Oh no, I couldn't reach that from a chair. I would have togo and get the steps. But even steps I suppose at our age is a bit dangerous,isn't it? But I feel determined to do my own work as long as I can. Yeah, wellas long as we can. It's the best thing to do isn't it? Or you'd be dependent onother people all the time. (LayInt2, General Elder, Female)

Resp J: That I think is it more than anything else, feelingthat your not independent any longer.
Resp C: And embarrassment, especially if you fall in thestreet, you've got to go and get somebody to pick you up, you know, "I'malright, I'm alright, I don't want any body." (LayGroup1, Active Males)

Resp M1: The only think I'm a bit nervous about is changingthe bulb on the upstairs landing light, because I'm right at the top of thewell of the stairs. I get up and I balance myself and I take the bulb out. Icould get Keith to do it when he comes home but I just don't look down. I stilldo it.
Resp M2: I won't wait. That's exactly like me - you know, doit yourself. (LayGroup4, General Elders)

Another participant in the group enquired whether these twowomen might consider altering the lighting:

Resp G: Could you not have... now this is an example of whatyou're talking about - like having a table at the top of the stairs with alamp?
Resp M2: Oh I've got a fitted cupboard with a lamp on!
Resp G: So you don't really need the light up there?
Resp M2: But I still go up the ladder!
Resp U: Oh M!
Resp G: It's dangerous. What would it take to stop you goingup? (LayGroup4, General Elders)

To which there was no response!

Professionals sometimes felt impotent in the face of olderclients’ determination to be independent - just as, no doubt have thefamilies of many an older person:

Some of them are so independent they will try it and theyend up on the floor. (ProfGroup2, Chiropodists)

Yet, it was quite clear that there was real respect forolder clients’ independence among the professionals we interviewed:

So again it would depend on how the person functions on theassessment. Whether we feel that they would be independent but safelyindependent or whether they need a nurse to actually come in and assist them,and that would be negotiated with the person. (ProfInt5, OccupationalTherapist)

4.9 Emerging constructs

These data can be explored in very many ways: while theremay be differences of emphasis and interpretation we believe that a number ofkey defining and explanatory constructs can be discerned.

First, the language of fall is crucial. Thelinguistic terms used by older people to talk about falls are neither neutralnor value-free, and imply quite specific notions of causality andresponsibility. The very similar distinctions drawn by lay and professionalrespondents denote not merely differences in definition, but also differencesin meaning and significance.

Second, those who fall are perceived in negativeterms to be old, frail and dependent and, possibly, to have a drink problem.The differential use of language to talk about trips rather than falls servesto distance respondents from the negative connotations of falling.

Third, falls are generally regarded as a future riskand not a current concern, and are mostly not salient at younger ages.

Fourth, the concept of a healthy older age is seen asdesirable and achievable via activity, gainful pursuits, and continuingindependence.

Fifth, although old age is regarded as a state of mind, theimpact of bodily change and limitation can dominate individuals’ability to remain active and independent.

Finally, social and cultural differences inacceptance of the ageing process can influence perceptions of risk,vulnerability and dependence.

The next chapter further explores these six constructs.

4.1 The significance of falls for older people

All those participating in the individual and groupinterviews were aware that we were interested in talking to them about falls.We tried to make clear that it was not necessary to have experienced a falloneself to take part and that we were interested in the views of people who hadnot fallen. In practice, we realised that it was inevitable that those with afalling experience might be particularly willing to participate in the study.As it transpired, almost all participants could recount a falling experience– either for themselves or someone they knew. As the analysis proceeded,however, it became clear that a person’s previous experiences influencedthe ways in which they talked about falls.

Although many had experienced what might be regarded as"a fall", these occurrences had a very different significancedepending on the context or way in which it occurred. The definition of a"fall" as such was closely linked with perceptions of causation.

Falls were significant events, not simply because of theinjuries that might follow, but in more complex ways because of the potentialimplications of a fall. A frail woman in her 70s, who had fallen on a number ofoccasions, went so far as to describe falls as the "worst thing":

It's a horror. Falling is the worst thing that can happen tous. The worst thing. (LayInt6, Frail, female)

It was also apparent that fear of falling again was a commonconsequence of a fall, but was not necessarily something that dominated theconcerns of those who had not already fallen:

So as a result of that, this is what we were saying, I'mcautious now. I'm not frightened of the fall; I'm more frightened of the resultof the fall. (LayGroup4, General Elders)

I think when I fell my first reaction was of great fearbecause I was alone at home and I didn't know how bad my fall was or if I'd beable to get up… It didn't seem very serious so I was very relieved, but myson was more scared than me after that. (LayGroup4, General Elders)

My confidence has suffered more after that fall. Now there'salways that fear at the back of my mind that next time if it happens I won't beso lucky (LayInt8, Asian, female).

Most of those who fallen, felt embarrassed about their fall.

I just felt stupid when I got up and looked round about tosee if anybody was watching. (LayGroup3, Active Females)

I think to be honest, with most older people it's not somuch the fear of falling or fear of anything, it's the embarrassment of havingto get other people to help them. That's really, well to me that's what itseems like. (LayGroup1, Active Males)

That's a natural thing, if you fall, you look around to seewho's watching you. (LayGroup3, Active Females)

I never was so affronted in my life. And this young chap andhis wife come along and said, 'Have you hurt yourself?''No,' I says. (LayInt6, Frail, female)

Although people feared falls because of the injuries whichmight be sustained or because it would be embarrassing, but perhaps alsobecause there was an underlying negative perception of people who fall, and aconcern that this would be the perception of on-lookers. There were two tellingconcerns: first, that people might assume that you were old and frail and,second that people might think you had fallen because you were drunk.

These people who fall are old. (LayGroup1, Active Males)

It's uncertainty. I know you'd like to go over and help thembut at the same time the other thing is "What am I getting involved inhere." Because you don't want to get too involved. Is he drunk?(LayGroup1, Active Males)

These views were not expressed directly, and never inrelation to ones self but, instead, were deflected onto others:

But when you see them all concentrated in XHospital….you know, the people getting out of the handicapped cars andthings like that, you feel sorry for them. You see them walking up or maybegetting help with their chairs, but it's not us. (LayGroup1, ActiveMales)

Participants were well aware of the potential links betweenfalls and dependency. The fear of becoming a burden on others as a result of afall was expressed – sometimes with great emotion:

When I first fell, it was shocking and very disturbing, butit was expected, because after the stroke…. I had had been bumping intothings for many months before my first major fall but it was not too bad Isuppose because I was at home and my wife was there. She is always around. Sheis very good. My sons when they come for visits are very helpful too ..I havebecome a complete dependent…I am so very nervous and helpless now at alltime. I wish I would die soon and relieve everyone of the burden. (LayInt9,Asian, male)

5. Beyond generalised constructions of falling

5.2 Design of Phase 2 of the research

The second phase was based around focus groups with olderpeople, many of whom were mostly not yet in the age group regarded, clinically,as being "at risk" of falling. The aim was to explore theirinterpretation of the data arising from the first stage of the study inrelation to the definition, attribution and prevention of falls using exampleswithin each category derived directly from the stage 1 data.

The quotes selected were felt to exemplify the six keyconstructs which had emerged from the first stage, which might be seen ascontentious and which would, therefore, promote debate. The group facilitatorchallenged responses by introducing those constructs which the data suggestedstructured the meaning attached to falls and falls prevention such as:independence (and dependence); confidence (and fear); activity and fitness,identity as an older person; and resources

The composition of the focus groups.

The focus groups reflected the diversity of older people(aged 60 and over) in terms of ethnic origin, gender, locality, current maritalstatus, and social status. In all, 10 groups were conducted in two contrastingareas: the first was Leith in Edinburgh, which is urban and contains pockets ofmaterial and social deprivation, and where work with older people around healthand safety issues has been developed. Contact was established with a localcommunity organisation and access was negotiated. One of the groups, with Urduand Punjabi elders, was conducted with the assistance of a translator. Thefirst stage of the study had speculated that Asian elders had a ratherdifferent perspective on issues relating to age, health, and risk and whichmore readily accepted and adopted the limitations of ageing. We were advised,in our approach to Asian elders in Leith, to shift our definition of older agefrom 60 years and over to 50 and over. Had we not, it is quite likely thatpeople would have been unwilling to participate – feeling that we clearlydid not understand their perspectives and culture. In this sense, we gatheredearly validation of our initial observations.

The second area, in the Borders area, is rural or semi-ruraland less deprived. The groups were more general, and included attendees of abowls club, an activity class and an over 60s club. Chapter 3 describes thegroup participants in terms of age and gender. For the most part the groupsconvened in Edinburgh were with older, and those in the Borders with younger,people.

The foci forgroup discussions

The discussions were all based around quotes taken directlyfrom the first stage of the study, which were felt to exemplify the keyconstructs which were felt to emerge from those data in relation to thedefinition, attribution and prevention of falls, and in relation to perceptionsof older age and risk in general. Each focus group considered several quotes:the aim was to cover examples of quotes around issues of definition,attribution and prevention rather than every quote.

The quotes we used are presented in Appendix B: within eachthe group the facilitator asked respondents to comment on the "truth"or otherwise of the statement and to discuss it in more detail. Allparticipants had a flash card with the quote. The method appeared to beeffective and stimulated considerable debate, disagreement and exploration ofthe core constructs. The results are presented in relation to the six keyconstructs identified earlier: defining falls; perceptions of falling;perceptions of risk; defining older age; health in older age; and, social andcultural perspectives of ageing. The table on the following page represents thekey constructs each quote was intended to exemplify: each quote inevitably hadseveral potential meanings and we have tried to reflect this within the tableand the analysis.

5.3 The language of falls

The data thus far suggested that the ways in which the olderpeople talked about falls – the terms they did or did not use, and whetherand in what ways they talked about issues relating to themselves or others– were quite specific, and were neither neutral nor value-free. Throughoutthis element of the study we were less interested in whether participantsactually agreed or not with the offered statements, than in how theytalked about the issues.

Trips versus falls

The data gathered in the first stage appeared to suggestthat the definition and attribution of falls and trips were conflatedconceptually by older people and professionals: falls were perceived asunpredictable events which occurred to "old" or "frail"people, usually as a consequence of a medical condition. Trips, on the otherhand, were defined as environmental or externally caused events which could(sometimes) be anticipated, but which could occur to anyone – regardlessof age or health status – as a result of carelessness on the part of theindividual for not seeing a hazard or an organisation for creating anenvironmental hazard. In older peoples’ narratives there appeared to beconsistent linguistic shifts from that of "falls" to that of"trips": in the absence of a diagnosed "medical condition"or overt frailty which "explained" a fall, people preferred to talkabout trips and to explain falling events in those terms rather than as falls.Trips, slips and stumbles appeared to represent the legitimate ground aroundwhich falling in older age could be discussed.

In this second stage we wanted to explore this observation:was it maintained by respondents and, if so, in what ways was the language offalls constrained and patterned.

There was a similar tendency to avoid using the word"fall" to describe an event in which the person landed on the ground:

WHEN YOU SAY YOU'RE ALWAYS FALLING? I'm always falling, I'malways tripping. YOU'RE ALWAYS FALLING OR ALWAYS TRIPPING? Always tripping up... always tripping but I go down. (FG3)

I don't believe that because I had a bad fall down the Walkand I tripped and I feel and I was in the hospital for six weeks..(FG3)

I fell down the steps, I simply .. I didn't look and that'sit, I tripped over a tiny wee kerb and smashed all my teeth and I fell at thesurgery because I hadnae looked at what I was walking on and it was a .....something sticking up. (FG9)

A distinction between events which could be anticipated orfor which there was perceived to be an external cause were invariably definedas "trips", whereas those for which there was no warning, could notbe anticipated, or which were perceived to have a physiological or internalcause were invariably defined as "falls".

If you fall spontaneously you've got something wrong and ifyou trip ... anybody can trip. (FG6)

Resp 1: No you don't get a warning when you fall youjust…Resp 5: It just happens. (FG1)

Whereas tripping was often portrayed as an externalisedevent – an accident and something which was caused by extrinsic factorsand happened to the individual, falling was seen as seen as anintrinsically physical event – a bodily occurrence, over which theindividual had no control.

Resp 1: No you don't get a warning when you fall you just.
Resp 5: It just happens. (FG1)

Eh well they since found out I had sugar diabetes andobviously I had gone dizzy and I just went down like you know ...... RIGHT, SOYOU DIDN'T TRIP OVER ANYTHING YOU DON'T THINK? No I just went down, I feltlight headed. (FG3)

Well it's different if you get a fall, a fall is alright butI mean if you trip over something and you could jerk something in your body butwhereas your fall you're actually falling bodily. WHAT DO YOU MEAN B WHEN YOUSAY YOU'RE FALLING BODILY, WHAT DOES THAT MEAN? Well you dinnae .... the wholebody is falling. You can walk along the street and some of the kerbs are notlevel and you can trip over the kerb and you can give yourself a right goodjerk ... but if .. to me if you're falling you're falling bodily. (FG1)

A term which was used by respondents in two of the groups,to distinguish between falls and trips which extended the construction of fallsas medical events , was "collapse": a fall was a collapse.

As X says like getting out of your bed too quick yousometimes, it's no exactly a fall it's a collapse you know you go dizzy ....well I've had that with ... I had tablets at one time and they were messing upmy blood and I'd go into a bath and get out of a bath and I'd be walking intothe lobby then bang I was lying on the floor .... but there was a reason forthat and it was the tablets I was taking that was causing it, it wasnae a tripor anything it was just a collapse. WHAT'S THE DIFFERENCE BETWEEN A COLLAPSEAND A FALL? Well a collapse ... you more or less ... you go limp and fall andthe chances of hurting yourself are limited whereas a trip you actually try andsave yourself and then you could be hurt, where it's better to fall relaxedthen fall tensed. (FG7)

He continued:

Well the thing about tripping is it's like getting a frightand you brace yourself and your try to stop yourself whereas a collapse ... thekind of collapse I'm talking about, I was just walking along and the next thingI was lying on the floor and I never even knew .... I didnae save myself I justfell.

The use of "collapse" denotes something over whichthe individual has no control; it is something which "just happens"and is seen as indicative of an underlying illness or medical condition. Forexample:

Well I fell just about a year ago ... minding my ownbusiness and I fell down the town right plonk, that was the first I knew aboutit and it did nothing to me except a few wee chips went into my finger thereand a few wee chips went into my knee and I picked myself up and I didn't tellanyone, I didn't even tell my husband and then I thought I'd better because wewere going out for a show the following night and I thought well if I'm goingto collapse at the show .. if there was anything wrong with me, so I told myhusband and I got hell from my husband for not telling him. (FG6)

Not just older people

Respondents frequently dismissed the idea that falls were,per se, linked to older age. Many brought up examples of young people who fell:

Resp 4: I mean my middle girl, now even when she was a weelassie her knees were always scarred you know .. there was nothing wrongwi’ her, I had her to the doctor an that. Pat's got a big scar rightacross there where she fell on top of a broken milk bottle….But when youget older I mean it tells on yea.
Resp 2: Aye of course it does.
Resp 4: No you cannae pick yourself up and say "ochwell". (FG1)
Yes it does shake you up, I mean it shakes me up more thanit does one of my grand daughters, they fall over, pick themselves up and runaway but me I've to sit down and get over it ... you know it does shake you up.(FG7)

DO YOU THINK YOUNG PEOPLE TRIP JUST AS OFTEN AS OLDER PEOPLE?
All: Oh yes, oh aye.
Resp 1: I mean some of them wi the shoes and that they wearthey're entitled to fall are they no? SO ANYONE CAN TRIP, NOT JUST OLDERPEOPLE?
All: Oh aye, anybody. Resp: Even wee bairns trip ken whit Imean. (FG5)

All: Anybody can trip.
Resp 1: Oh no anyone can trip, young people too aye ... ochmy bairns used to.
Resp 3: My nephew he's the same, always falling and trippingup you know.
Resp 1: Anybody can trip. (FG3)

Resp 1: At any age anybody could trip.
Resp2: A child could trip. (FG6)

My daughter broke her ankle at Gym Club but the orthopaedicsurgeon said that anybody could have a similar break just walking along thestreet and you don't have to go over a pebble or anything, her ankle just wentand eh ...that's what he said that you know, you didn't need to be old or goingto one side. (FG8)

No I don't, I think it's just accidents you get people cantrip over a hole on the pavement or something, no I don't think it depends onyour age. (FG8)

[Via interpreter] Because of not right balance people fall,no control over yourself in balance and if they tripped over something they canfall. They said that even the young people fall. (FG4)

For some, however, the distinction was not clear-cut. Again,though falls were not seen necessarily perceived a something which happenedmore to older people, there were seen as having more serious consequences atolder ages.

When yea get older definitely you cannot .. you cannae getover it as you can when you're younger but em .. actually I cannae tell you thedifference between a trip and a fall. (FG1)

So, who does fall?

As in the first stage, the younger respondents (the under75s) were less likely to see themselves as potential fallers. Fallers were oldpeople, frail people, people with health problems. In short, the perceptions offallers were "other people" and, notably, people who were not likethe respondents because of some perceived bodily and mental failing be it"old age" with its implied infirmities or be it other perceivedpersonal defects.

You're sort of dizziness or something. Up till now I haven'tfallen - touch wood - so I'm not really sure about that. (FG5)

I think some people as they get older tend to look .... likemy mother she is eighty odds and she's kind of ... she walks about like she'sbeen on the drink you know but she hasnae actually and she's liable to fall but..... and she hasn't yet fallen but the doctor says we've got to sort of takecare. (FG7)

When the younger or fitter respondents talked about whofalls, they did not use the first person: the accounts were almost always inthe distanced third person plural, as in (our emphasis):

Resp 5: Well I've heard people saying that they get abit faint you know ... you know and they start to tremble a wee bit some ofthem, don't they?
Resp 6: They get the shakes.
OKAY FAINTING, TREMBLING ANYTHING ELSE?
Resp 7: Some people have arthritis and have a hip ora knee that just gives way without any warning, they'll just be walkingalong and suddenly that joint gives way and they fall. (FG8)

5.4 Negative connotations of falling

It was apparent in the exploratory phase of the study thatfalls carried with them negative or unpleasant connotations: those who fallwere perceived to be old, frail and dependent and, possibly, to have a drinkproblem. In those terms, it could be suggested that the differential use oflanguage with a preference to refer to trips rather than falls served todistance respondents from those negative connotations.

Embarrassment

Almost all those who had fallen (or "tripped")felt embarrassed and, in some narratives, this was the over-riding feelingassociated with the event:

Resp 2: Yea the first thing you look for is anybody seenyou.
Resp 1: It's embarrassment.
Resp 6: And your pride is hurt. (FG7)

Well I daresay I do. The fear is there an all but theembarrassment of helping you. That's true isn't it? it's the embarrassment ofsomebody helping you to get up. (FG10)

Well, I mean I fall and a lot of people come up to help meon my feet and oh honestly I'm glad to get indoors because I felt soembarrassed at falling and them having to help me up. (FG3)

I helped a woman coming down the green and the pavement wasall slippy, it was icy and she fell and she wasnae bothered about broken bonesor anything although she was black and blue after - I seen her two or threedays later - she was more upset about he having to pick her up you know. (FG8)

Although some did not wish to acknowledge that theirembarrassment might be due to a concern that others might regard them as old orfrail if they were seen to fall, the following exchange suggests that the topicis fraught and sensitive.

Resp 5: Would the embarrassment be because you felt oldbecause you fell?
Resp 1: Yea.
Resp 5: Would you feel the same way if you were younger,cause I certainly do feel embarrassed?
Resp1: Even if I was younger I would feel embarrassed. Imean I'm not that old, I mean I'm only ... sixty eight, I mean that's not old.
Resp 5: No, I'm not saying your old. (FG3)

Drunks fall

A factor which clearly does add to any sense ofembarrassment, is the concern that others will think that the faller has beendrinking or, worse, is "a drunk". In a number of the accounts,participants did directly attribute falling to alcohol consumption talkinginstead about how drunks do not seem to hurt themselves when they fall, but theidea that fallers are drinkers (or drug-takers) was a frequent sub-text.

It was a right place to fall, right ootside a pub. (FG5)

I mean you used to see them in Glasgow, coming out andthey're absolutely steaming and then they fall and they never seem to hurtthemselves. (FG2)

But there's a funny thing, how does a drunk man never hurthimself when he falls, is it because he's drunk? (FG4)

Given the negative view of the alcoholic, it is notsurprising that people wished to distance themselves from something perceivedto be a consequence of drinking.

Resp 2: Oh no I think that .... an alcoholic asks for all hegets and I just wouldn't attempt
Resp 4: All these filthy ones that's going about.
Resp 2: And anyone at all, the drunks… in my mind theydon't deserve any help, if they get to that state well it's their own fault,I'm very protective about that one.
Resp 3: I'd be frightened to help them in case they attackedme.
Resp 2: I must admit I don't drink myself but I thinkthey're mad, I don't mind people having a drink but when they get to that stageit's their own fault entirely.
Resp 3: I would avoid them.
Resp 1: I think I would look at them to see what was wrongyou know and I'd stand back from them but I would look at them and if I thoughtthey were seriously hurt in any way I would definitely make a call. (FG2)

Resp 2: Oh aye that's right aye, see and now you'refrightened because you dinnae ken, there's that many drug addicts going abootyou know.
Resp 5: It's no just drug addicts I mean there's a lot offunny people I mean a lot of drug addicts they're no really bad people. (FG1)

Old people fall, silly people fall

While there was a general view that falling or, moreaccurately, tripping was not confined to older people "fallers" werefrequently portrayed as "old" people – older than oneself but,perhaps more importantly, frailer or less with it than oneself."They" were people that one pitied.

I feel sorry for them ... very sorry. (FG5)

Just as if there's a stone in your way and you just....you're getting old and dottery and you haven't seen it. (FG6)

WHAT DO YOU THINK OTHER PEOPLE THINK ABOUT PEOPLE WHO FALL?Stupid devil.

There was tendency to think of fallers as "types"of people, for whom help or support may be necessary. Again, the narrativesmostly referred to others and not to the self.

Aye but I was meaning like if you had something wrong withyou ... your balance or your eyes and you thought that that type of personwould maybe fall they should maybe use a stick, just be cautious. (FG8)

If you're inclined to be a faller you should use a walkingstick. If you're that type of person. (FG8)

Aye that happened to my mother she fell three times andthere was nothing there to trip over or anything. There was nothing there totrip over ... she was over eighty you know. (FG4)

5.5 Salience and the perception of risk

The propensity to give examples of falls which related toother people seems to confirm the earlier observation that falls are not onlynegatively perceived, but are generally construed as not salient and, at most,only a potential future risk. Those in the younger categories (less than 75years) were willing to recount examples of trips which they had had, butto refer to falls occurring to others – their own parents or othersin the community who were perceived as old, frail or ill. The samples didinclude a number of older people (75+) and some who were quite frail: many hadexperienced what they deemed to be falls (they were generally more prepared touse the term), and it was clear that their perspectives were different from theyounger participants. In particular, a previous fall had led to heightenedanxiety.

Previous experiences

Resp 4: But having had a very bad fall, I have afear of falling, now that's….
Resp 0: Aye I'm terrified of falling too, I'm scared of afall.
Resp 4: In the 80s eh .. a fractured hip and a fracturedwrist and I still have a fear of falling. (FG5)

Resp 4: I think it's the thought of falling, ayewell you see when I fell and broke my hip I got an awfee fright and you'realways sort of wary aren't yea.
Resp 2: That's right aye you've got that fear, aye.
Resp 4: You've got that fear, sometimes when you go out youtighten yourself all up because you're frightened you're going to fall, it'sjust a natural reaction I think. (FG1)

Careful, yes. It goes against the grain to haveto use the stick first of all and not being able to ... I never used to walk Ialways ran, now I crawl. (FG5)

Resp 4 : Well there's one thing in my house Ialways say is dangerous, that's my big carpet there but I've got my ... anordinary carpet just like that there.
Resp 0: A wee rug?
Resp 4: Aye .. I think that's bad.
Resp 2: Well take it away.
Resp 4: I'm saying that to myself, I'm daeing it wrongbecause I could trip over the edge of it.
Resp 2: Well take it away ...... throw it oot.
Resp 4: I'll no take it away though, that's why I bought itbecause I like it.
Resp 2: Well there you are, it's your ane fault.
Resp 4: I know.

Living alone

Those who lived on their own perceived themselves and wereperceived by others to be at greater risk: there may be risks associated withhaving to do things for oneself (such as changing lightbulbs), but theperception of greater risk was seen to lie in what would happen if one did fallrather than in being more likely to have a fall.

Yes especially when you're in the house on your own….
WHY IS IT TRUE?
Because you ... you wonder how in the name of god you'regoing to get up again, that's what always worries me. (FG10)

I would say falling even in the house is theworst thing that can happen to you when you live alone, you know if you livealone I think falling with weak knees. I've had a bad fall ... it's alright ifyou were able to crawl to the phone or anything like that but that's the onlything, falling in the house ..... falling outside wouldnae bother me so muchbecause I know there's people going up and down but falling in the house wouldbe bad. (FG3)

5.6 Health problems and older age

Falls were associated by respondents with frail old age andthose with health problems perceived themselves to be fallers or potentialfallers.

I occasionally feel I want to fall, only because some partof my body lets me down, it's not that I feel I want to fall or anything likethat it's just that my knee goes or my hip goes and I'm sort of thinking aboutit. It just happens.
YOUR BODY'S LETTING YOU DOWN?
Aye, only because of my injuries. (FG2)

(Via interpreter): He doesn't go to those places. Yes hesays he is very careful, very slowly he goes up, like the way he came up. (FG4)

Well I get osteoporosis so I agree entirely that far,however a lot worse has happened to me than falling so no I don't agree. (FG6)

Younger groups much less inclined to relate issue tothemselves, but as salient or relevant issue for known or unknown others whoare older and frailer.

I think some people as they get older tend to look .... likemy mother she is eighty odds and she's kind of ... she walks about like she'sbeen on the drink you know but she hasnae actually and she's liable to fall but..... and she hasn't yet fallen but the doctor says we've got to sort of takecare. (FG7)

Well looking at my husband I'd say that it's easy to fallbecause he's had three hip replacements and he's also had .... he's gotarthritis which makes it difficult for different parts of your body, you knowyou get arthritis in your shoulders therefore you can't lift your arms and soforth, and also the bottom part of your legs are affected as well and as youget older - cause he's 85 now - as you get older so it em .... age I think hasa difference as well as his disability, I think the two go together andespecially if you've other conditions cause he has high blood pressure and healso has prostrate problems so there's all these factors come into play andwhat you've got to watch… (FG2)

Resp 6: They don't lift their feet
Resp 0: That's what I was going to say you don't lift yourfeet so much
Resp 1: And their balance isn't quite so good.
Resp 6: And they're like a baby learning to walk lots ofpeople.
Resp 0: They're looking the other way .... they're losingthe art of walking.
Resp 0: And older people get tired probably if they arewalking and if they get tired they could be liable to be .. you know a bit careless and trip up or something. (FG7)

Well I've heard people saying that they get a bit faint youknow ... you know and they start to tremble a wee bit some of them, don't they?(FG8)

5.7 Old age and boldly change

Although old age was regarded by many as a state of mind"you’re only as young as you feel", the impact of bodily changeand the limitations a failing body exerts often dominated individuals’narratives. It was clear that, for many, the ability to remain active andindependent was profoundly affected by their physical health.

Resp 4: When you begin to feel old is when you stop walkingken on a long distance .... I used to walk a lot.... ken walk round aboutCorstorphine and that, now I wouldn’t do that for the life of me ... youstart to feel old when somebody else beats you walking.
Resp 3: Aye you cannae walk so fast too and someone passesyou.
Resp 4: That's what I'm saying when you stop walking….
Resp 1: Well that's right because up to a year ago I couldwalk along that Junction Street no bother ... I could walk it but no now, Icannae even walk up the wee bit incline, I've to stop a couple of times. (FG10)

When they're physically disabled, eh hum I think that makesthem feel old, my husband is physically disabled and I think that is one of thetimes when you will feel old because you can't ... you're not able to do thethings you normally done. (FG2)

The mental/physical divide

Feeling young was linked with mental processes – anactive mind, feeling good about yourself, wanting to be involved in activities,having a social life. Being old, on the other hand, was linked with physical orbodily processes. The division was not absolute but lurked behind the laynarratives: you might feel young "in yourself" but your body couldlet you down. It was one’s body which seemed to give lie to the beliefthat one was not old or had not changed.

Old people were portrayed as mentally old: people who had anold "outlook" were regarded disparagingly as having "given up onlife". There seemed to be a belief that as long as one maintained a"young outlook" one was not old: the need not to be old and not to beseen as old was central for many people, even if their bodies sometimes failedthem or "let them down".

Aye but what I'm saying is ... we know everybody grows oldbut it's how you feel. (FG1)

Well I've never felt old, I just feel young and I just wantto do things and keep going, now I'm a dance teacher and I get plenty ofexercise and that but I never feel old and I never look at it that way and whenyou keep young I feel young and I keep Johnny going………….(FG2)

Resp 4: Yes it's their attitude, I know a lot of folk arelike that, they've retired and "Oh I'm old" and get this done, but alot of them play on their families, they do they just expect their families todo it.
Resp 3: Aye my mother, well she was ninety when she died butshe ran the shop up until she was seventy seven. (FG3)

….then of course with my husband he's got…. he'sasthmatic and eh ... and yet but he doesn't ... you know some days he says hefeels old but eh you know he's got plenty good outlooks really considering he'smore or less housebound. (FG5)

Well you've got to feel old to be old. (FG6)

SO WHAT IS IT THAT MAKES SOMEONE OLD, WHEN IS SOMEONE OLD,WHAT MAKES SOMEONE OLD? When their age gets them down, when they're governed byhow old they are, you know you wake up in the morning and you think I'm sixtyor whatever and you're finally past it. (FG6)

Again and again, the participants dismissed chronologicalage as the significant factor determining their self identity: age may be feltto come into the equation, but only if the body had let one down.

I'm eighty three, well I will be next month and I feel aboutfifty and when I look at things like clothing I say oh I like that and then Isay oh god I'm too old for that, it's for younger ones but I don't feel my age.(FG10)

You see people in their seventies are still working, myhusband he doesn't feel old and he goes to the gym, he's on the golf course andhe's working at the Post Office you know and he doesn't feel his age, it's todo with outlook. (FG6)

The point at which one "felt old" was invariablywhen (or if) physical or bodily failings developed.

But it's very tempting to give up when everything gets sodifficult, I've haven't been without my sight for many years, it's onlyhappened about four years ago that they gave up and eh you simply have got tostop feeling poor little me and you get round it like that but you have rottendays sometimes but .... I mean I'm not giving up. (FG1)

Once you get past .. seventy or over that's when all thetrouble hits you. (FG1)

[Via interpreter] He's saying from the body, he can't do thesame things as he used to do. (FG4)

Old people were inevitably, those older than oneself.

SO TELL ME WHEN IS SOMEBODY OLD?
Oh when they're in the 80s and 90s, you know, things likethat. (FG3)

Despite body failings, the desire to maintain a"young" or "positive outlook" and not to be"old", persisted and clearly defines self-identity.

Well I try as much as I can, eh my body begins to feel oldbut in my mind I'm still young, in other words I find it's better to bepositive about what you're doing to get there rather than negative. (FG2)

5.8 A healthy older age

The concept of a healthy older age was seen as desirable andachievable. There were, as we noted earlier, various dimensions to this whichfocused on remaining activity, having gainful pursuits, and continuing to beindependent.

Exercise

There is evidence that weight-bearing exercise may conferhealth benefits in older age and prevent falls (see Chapter 2). However, littleis known about how older people themselves perceive exercise: what do theyregard as exercise? Do they engage in formal exercise? What, if anything wouldencourage the uptake of these activities? In the exploratory phase, the issueof formal exercise was rarely raised so we explicitly considered it in some ofthe stage two groups. What emerged was a view that exercise in general wasregarded as an important component of staying fit and young, but that formalexercise in older age was perceived as something that only"exceptional" people do.

If they keep going and doing things that's forms exercise itkeeps your circulation going.
Resp 0: It keeps your mind alert too. (FG6)

Some did engage in sporting activities, and valued them. Thevalue, however, was more often than not in the social rather than the purelyphysical benefits.

WHAT ARE THE BENEFITS (OF PLAYING BADMINGTON? Not onlybodily but mentally you know our social lives. TELL ME WHAT THE BENEFITS ARECOMING HERE? I stay in a so called old folks home, it's not, it's a retiredhome for gardeners and there's some of us ... well possibly a wee bit likemyself, alert and wanting to get out and play badminton and there's one or twothat just sort of sit in armchairs, oh and I'm old and that's it. (FG6)

But the role of exercise in keeping healthy was not accepteduncritically, and a number of respondents questioned the importance of formalphysical exercise as the route to a healthier old age. In particular, it wasclear that exercise as a health promoting agent was perceived narrowly in termsof formal exercise classes or routines rather than in terms of generalactivity, but there were criticisms of that focus.

Resp 4: No, I've never done exercise, well I do something inhere with a cap but I never do exercises, never.
Resp 1: No.
Resp 3: Not now, I used to.
Resp 4: Maybe it does help but I've never had to doanything. (FG3)

I don't think that's particularly true when you're talkingabout formal exercise, I mean you get people who have been housewives all theirlives and everyday they're doing something it's exercise but they don't realisethey're doing it. (FG5)

Are we talking about, necessarily talking about physicalexercise? (FG6)

Cost was mentioned as an inhibiting factor:

Resp 1: Well the class that I go to is the XX exercise class- you've probably heard of it - for the over fifties and it's tomusic.
Resp 0: I've been but it's so expensive. (FG5)

Participants stressed the role of everyday activity as ameans of staying fit but also and, perhaps most importantly, of maintaining anactive mind.

Well with us we're into Country and Western and everythinglike and we play dominoes, we're very rarely in the house like you know, and wego out and about visiting friends and they come here like you know so eh ... wedon't get tired/hemmed in and I've got my family so we don't get tired. (FG3)

Resp 0: I think it is in our days, there's too many carsnow.
Resp 6: ell I ken a chap, he retired the same time as me, hewas married, he gets up in the morning, gets his wife to godown and get him a paper and brings it back and then he watches television andhe watches horse racing, he's never out and he's had days ... he's still ayoung man, he's still the same age as me, I feel that he's no taking aninteresting in anything.
Resp 3: He'll no get as much out of life as you just sittingwatching the telly all day. (FG8)

The social dimension of "exercise" and its role as"an interest" were particularly stressed:

Resp 1: No it's no just the physical thing of the game,you're enjoying it and your meeting the company.
Resp 4: The company has got a lot to do with it.
Resp 3: You have a good laugh and a natter to each other.
Resp 2: If you get someone who is agitating all the time iteven makes it better LAUGHTER. No but that's ... it keeps usalive just meeting each other and chatting and having an argument and all therest of it now and again you know. (FG7 – Bowls Club Group)

Images of older people engaging in taxing exerciseactivities were not seen as necessarily positive, and were not seen asreflective of the general population.

I mean the only .......... och you see the London Marathonfor instance you see old people running in that but they're an exception, Imean that's not like everybody, they're exceptional people but the likes ofordinary folk. (FG1)

Independence

The construct which most markedly defined anindividual’s identity as "not old" was independence. There was awidespread view that as long as one was independent – that is, able to dothings for oneself – one was not old.

Well as long as I can get out and go .. you know do my ownshopping, I do my own cleaning, I'm on my own you know I live on my own and aslong as I can get out .. I mean I go away ever week - nearly every week-end -to my sisters and we go out visiting and things like that, but I don't feelold, I just don't feel old. (FG3)

I don't feel old but I can imagine that I will feel old whenthe day comes when I can't do things for myself, when I have to get somebody tohelp me with basic things. (FG8)

One respondent talked about the need to, as she put it,"keep my initiative":

I mean I had an operation last year and my daughter calledon me and I felt that I was losing my initiative and I sort of started sayingnow I'm going to do this and I'm going to do that and I think it's doing thatkeeps you young. (FG5)

Falling violates an individual’s sense of, and maycritically compromise, independence. The narratives may focus on issues such asembarrassment but the use of words such as "silly" to describe theevent suggest that the concerns may be more deep-rooted. The evidence relatingto the impact of falls on individuals would indicate that these concerns areboth real and valid.

Away back to this independence thing again, the fact thatyou fall, you're embarrassed that you've been so silly as to fall and somebodyhas to come and help you and it's really embarrassing. (FG8)

5.9 Risk and help-seeking

Perceptions of "risk" are not clear-cut and may bevery difficult to articulate. In order to elicit narratives which might providea window to perceptions of risk, we included, as one of the stimuli fordiscussion, a quote about help-seeking. Respondents had stressed the importanceof independence but we wanted to explore what might define the limits toindependence. Although the issue came up in other contexts, this particularquote asked about help to change a light bulb and if or when people did seekhelp for this task.

While, as we observed in the first stage, there are somerisk-taking dare-devils, it was obvious that a number of the older respondentshad become quite cautious and have a clear sense of activities which might nowbe more difficult (rather than dangerous) and for which they asked forassistance. The shift from feeling able to carry out a task such asbulb-changing to not feeling able was, like other perceptual changes, linked toan illness episode or previous bad experience which changed individuals’sense of their own capabilities.

Resp 3: Well with me it was because I took a stroke, I justcan't manage it, I mean apart from anything else my wrist movement ... so Ijust said I can't do it.
Resp 4: I'm the same so I wouldnae do it now.
Resp 1: I mean I'd just leave it until someone came, mysister or my sister-in-law or a brother ... I would never go up on aladder but I can ... I shake the whole time. (FG3)

I wouldnae even attempt it .... I couldnae even get on achair because my knees won't hold me. (FG10)

BUT WHEN WOULD YOU CHANGE IT .. YOU USED TO CHANGE IT YOURSELF?
Resp 0: Oh aye that was a long long time ago.
Resp 1: Aye when my knees started to go. (FG10)

Nevertheless, needing help with the task was linked to aphysical health problem rather than to being too old to do something anymore:

Resp 1: Aye but just because of our knees and that, no’because of how we feel.
Resp 2: We're just no able to. (FG10)

Some were reluctant to call on busy adult children –not because they wanted to be independent, but possibly because their childrenhad expressed annoyance at their dependence. For the Asian elders, who might inother contexts have expected an easier old age living in the same household astheir adult children, this was a cause for complaint. What emerges is thatasking for help with difficult tasks requires, at the very least, that there issomeone to ask and who will not mind being asked as the following exchangedemonstrates:

I WAS GOING TO ASK YOU WHO DO YOU ASK TO HELP?
Resp 3: The home help or the man upstairs.
Resp 2: The man next door.
Resp 4: I'd get a policeman.
Resp 0: Aye but you cannae always find a policeman.
Resp 4: You can phone the police.
Resp 0: Oh I wouldnae phone the police .... I just go to theman next door, he puts it in.
Resp 4: Well I havenae got a man, they're all widows in thestairs.

Resp 4: And they're busy, they are too much busy.
Interpreter: They have got their own lives and all that sothey try to avoid that just in case they say no to you ....... carefulhow many times you call them. If you are ill at home even if young children, ifyou ask them for ... give me water and medicine….(FG4)

Interpreter: They said before they say no to us they shouldtry ..... even young, I mean even if you're younger you know and if you have afamily living together and if you ask maybe three times something, then they'llsay "Oh mum that's enough", then you are going to be alright. (FG4)

5.10 Social and cultural perspectives

In the earlier phase of the study, we noted that Asianrespondents had a particular perspective which seemed to more ready to acceptthe ageing process and its limitations, to be fearful of taking risks, andwhich did not seem to value independence in the same way as the other,non-Asian participants. Ethnicity is, of course, just one very specificcultural factor which might affect constructions of risk and ageing. Othersocial and cultural dimensions include class, marital status, and area ofresidence: all of these are likely to influence perceptions of ageing, risk,vulnerability and dependence. It was not possible to explore each of these, butthe groups convened for this element of the study included one which was whollycomprised of Asian elders, and others which were conducted in areas of greatereconomic deprivation that had been considered before. Our initial observationthat Asian elders may hold different constructs of ageing was confirmed when itwas suggested that we recruit, not from those aged 60+ years, but from thoseaged 50 and over.

The Asian group was conducted by an English-speakingfacilitator but with the assistance of an interpreter. For the first stage, wehad the services of a native speaker, who was an experienced qualitativeresearcher. Although it was clearly advantageous to have the assistance ofsomeone known to the group – and, indeed, the group may have beenunwilling to take part in the study if we had brought in a native speaker notknown to them - there were some limitations. In particular, it was not alwayspossible to be sure that nuances of meaning had been understood and conveyed tothe group as we intended.

Nevertheless, it was clear that the Asian elders had arather different – although not universally different - perception ofageing.

Whereas the non-Asian elders talked of ageing in terms of"outlook" or of "feeling young" and eschewed chronologicalage unless or until such time as their bodies creaked , for the Asian eldersage was more likely to be delineated by life stage. While some respondents hadnoted that the arrival of grandchildren brought home to them some of theirphysical limitations (for example, one respondent had commented that she couldnot carry their grandchildren), for the Asian elders the arrival ofgrandchildren marked the social definition of someone as "old".

YOU SAID YOU FEEL OLD BUT WHEN DID YOU START TO FEEL OLD,WHEN DID THAT HAPPEN?
Resp 4: Papa, grandpapa and grandfather, everybody call mepapa so for that reason I can feel I am old. My eldest son you see he'seighteen, suddenly he can dance you see that. I have got four children.
Resp 5 for 4: Before he was retiredhe was a grandfather.
SO IT'S THE GRANDCHILDREN THAT MADEYOU FEEL OLD?
Resp 4: Oh yes.
WHY DO GRANDCHILDREN MAKE YOU FEEL OLD?
That's just an Asian concept, it's just a culture ...... anAsian culture. (FG4)

[Via interpreter] He said we try to talk in a younger manneryou know after we are a grandfather or a grandmother and then in the communitypeople will laugh "look at him, he's a grandfather and talking like that,like a younger person " so they have to… (FG4)

And:

Yes he also agrees that you have to behave in a certainmanner when you become a grandfather, you have to lead that kind of behaviour.(FG4)

Life changes were, generally, regarded as markers foridentity. For example:

When a girl got married, that mean she should get her actstogether. (FG4)

One participant did focus on his physical limitations as thedefining characteristic of feeling old:

[Via interpreter] No, he said no. He said no ..... he hasgot grandchildren but he didn't feel old because of grandchildren, he said hefeel old because of his legs, he says he can still re-marry. (FG4)

Another – as those in other groups had – thedifference between feeling young and being old.

[Via interpreter] She is saying her feelings is she isfeeling young because she says "I'm only 66, I don't think I'm old"and everybody says that she looks younger that her age but it's the pains andaches she gets, that's why she thinks she is old. (FG4)

The other groups made fewer references to life-stage orgenerational issues, save for comments that retirement should not mark thebeginning of the end for people. There was discussion of the changes in"outlook" and ageing between their own and previous generations.

Resp 1: They seemed to get old quicker, I mean I canremember when I was ... say about twelve year old or something my grandfatherwas only in his fifties but he was an old man at that time. Resp 0: Aye butthat's looking through different eyes. Resp X: That was looking through ayounger eye wasn't it. (FG7)

But the participant maintained that the difference was real.Echoing the point made by participants in the exploratory phase of theresearch, he argued that, for his parents’ generation, old age came atyounger ages. The "evidence" he gave related not to issues ofoutlook, but to physical signs of ageing.

Resp 1: He worked in the docks and it was hard work he donein the docks and he did .. he was an old man at that age, ken I mean he'd lostall his hair and all the rest of it. (FG7)

Resp 1: You know the bible says that your life span is threescore years and ten, that's seventy and if you think when you think when youcome to seventy well that's me I'm finished.
IS THAT HOW YOU THINK? Resp 1: No. Resp 5: No, but seventyis not old now is it? Seventy is not what it used to be.

5.1 Linking the stages of the research

The second stage of the study is intended to assess thevalidity of these constructs emerging from the data. Initially, it had beenproposed that this would be done through a series of case studies which wouldhave comprised interviews with older people "at risk" of falling andwith others involved in their care and considering how different constructs ofrisks of falling were applied. The data emerging from the first stage, however,suggested that differences between lay and professional constructions were notso very different, that many of the older respondents we interviewed hadexperienced a falling type event, but that falls were largely seen as a problemof poor health and "old age" and, for the most part, respondents didnot regard themselves as old or frail. Moreover, the lay narratives suggestedthat falls and falls prevention had to be understood within a broader contextof the lives of older people, in which the maintenance of an independent lifewas paramount; falls might prevent that and were feared for that reason but, inmore complex ways, total risk avoidance and containment were also seen asinhibiting a full and independent life.

The focus of the study is the primary prevention of falls– that is, the prevention of a first fall. But, the first fall is in factdifficult to define and discern – as far as many respondents wereconcerned falls – or, rather, trips can happen to anyone and are notage-related phenomena. While they might be more common as one gets older (andhere, respondents cited mostly physical changes associated with ageing such asdiminished sense of balance, poor eyesight, and problems with their feet andenvironmental factors such as uneven pavements as causes of falls), falling wasnot regarded as a problem merely of old age. What mattered for respondents wasthe prevention or avoidance of a consequential fall – the one thatwould cause serious injury, prevent them getting on with their life and maytherefore impinge on their independence. Independence was highly valued,dependency feared and older people may prefer to take some risks in order tolive an independent life in which they managed tasks on their own.

The data suggest that instead of focusing on the mechanicsof falling, there is a need to focus on broader processes of not falling - suchas: staying active and fit, having confidence in ones own abilities butmaintaining awareness of personal limitations.

Similarly, it was clear that the language of falls wascritical and a focus on "falls in older people" will not resonatewith those who are "not old" and do not "fall", but may"trip" in the same way that anyone might.

This posed a number of challenges for the second stage ofthe study

• To what extent were definitions of falls linked to perceptions ofattribution and prevention, and in what ways were constructs of health (i.e.being/staying healthy) linked to perceptions of the risks of falls
• Were falls perceived to be preventable?
• Were different kinds of falls seen as more or less preventable?
• What messages would resonate/be received by older people who:

- may not be and did not necessarily regard themselves as"old" and
- may not do so for many years hence;
- did not regard themselves as currently "atrisk";
- may regard risk containment as inhibiting a full life

• Is behavioural change in advance of a later risk is seen as the (an)appropriate strategy by older people? Can/will older people make small changesin advance of any problem to prevent future problems?
• Are the time-scales in which risk and future risk are evaluated differentin older age?
• What, if anything, would motivate behavioural change? Are factors such asindependent living and "staying young" motivators for older people?Is this any different from the factors which promote change in younger groups?

6. Discussion and implications

6.2 The language of falls

The general constructions which emanated from the firststage of data gathering were, to a great extent, confirmed by the second stage.The language that older people use to talk about falls is value-laden: fallsare negatively construed as medical events occurring to old, frail people and,possibly, to those with a drink problem. Within the lay and, to some extent,within the professional narratives, falls are unpredictable and, therefore,unpreventable. Lay respondents – especially those in the younger (pre-75)age-groups who might be regarded as the target population for any primaryprevention strategies – were mostly unwilling to perceive falls as eithera current or salient risk. Falls were invariably talked about by these youngergroups as something which happened to other people and the use of languageserved to distance people from the event. Even when people did talk about theirown experiences of falling occurrences, the terms used were not those of"falls" but of "trips". While falls were seen asage-related, trips were accidents which could "happen to anyone":trips were external and externalised events. Falls "just happened"and there was a strong sentiment that they were medical events which theindividual could not prevent. Trips were accidents with identifiable andpotentially remediable external causes.

In much the same way that falls happened to "oldpeople", so many of the respondents were "not old". Feeling andbeing old were perceived as distinct, but not wholly independent, entities: onewas construed as a mental state and the other as a physical one. The physicalstate – the failings of old age – was what ultimately could tip thebalance from feeling young to being old. Again, the younger elderly wereextremely reluctant to see themselves as "old": some still had livingparents and there was an awareness that an early decline into old age could behazardous. The need to stay young was often expressed and this was seen asachievable via maintaining an active and independent life and by having"interests".

6.3 Identifying areas and routes for legitimate action

The lay elders – even those who might by any criteriabe regarded by others as old, frail and who had experienced falls - werereluctant to identify themselves in those terms. At one level, this may not beproblematic: they represent a group for whom primary prevention, at least, isnot the issue. What it does suggest, more than anything, is the need for healthpromotion to avoid what is perceived to be pejorative language in discoursesaround older people.

These data suggest, first, that the language of falls and ofold age is critical. The very term "fall" is contentious: it hasnegative connotations and its use is likely to inhibit engagement with anypreventive programme. Similarly, people do not perceive themselves nor do theywish to be perceived as old. Targeting "older people" is also likelyto provoke a negative or non response among people who do not relate toportrayals with which they do not identify. The emotive connotations of fallssuggests that a simple focus on the issue may be negatively received or, evenmore likely, not received at all. For many of the younger respondents, fallsare perceived to be, at most, only a distant future risk: it might havehappened to old people they knew (including their parents), but it wasn’tan issue which dominated their lives or identity.

Second, the data suggest that the promotion of healthyageing rather than a healthy old age may be more attractive and accessible toall age groups. Indeed, it might be that a focus on age per se is aninappropriate way forward with groups who do not regard themselves as"old". Primary prevention work in relation to falls must target thosewho have not experienced a fall. While that group is seen as those aged 60– 75 years, it must also include younger groups who will be even lessamenable to messages about old age.

Third, the narratives indicate that, apart from some of theAsian elders who had a more heightened sense of personal risk and danger aroundeveryday activities, the issue for most people only becomes salient if someonehad a "bad" fall: that is, a fall for which there was no obviousexternal cause and which caused physical harm to the individual. Awareness ofhealth problems such as osteoporosis represents a possible route for discoursesabout falls prevention. Respondents felt able to acknowledge the risk and toaccept that a fall could be particularly detrimental to them. A further pointat which messages about falls might be "heard" is when the individualhas experienced a life change such as a bereavement. The change may bring intofocus activities the person had, hitherto, never had to do for themselves– such as changing a lightbulb.

Fourth, what most people appeared to want was to be able tolive their lives as they had, doing the things they enjoyed, and managingthings for themselves. Some of the respondents had gone to great lengths toconceal falls or health problems from family members whom they feared would seethis as an opportunity to intervene (interfere) in their life. Independence canbe fiercely guarded, but self identity as independent may inhibit appropriatehelp-seeking. This suggests that secondary prevention of falls may perhaps havea greater salience than primary prevention. However, even among those who havefallen there is a need for sensitive approaches which acknowledgeindividuals’ needs to be, and be seen to be, independent.

Fifth, lay respondents placed great store on the mentaldimensions of ageing: feeling young was valued and was perceived to derive frombeing independent and having interests. People were less convinced that theyshould, for example, take up new sports or formal exercise, and more interestedin ways of staying fit and active in ways which fitted in with "havinginterests" and with living a normal life. Within that context an emphasison the promotion of health ageing rather than a healthy old age may beperceived as more relevant, appropriate and achievable.

Finally, the research literature suggests thatmulti-factorial approaches which do not fragment personal experience but whichare sensitive to individualised needs are the most likely to be effective infalls prevention work. Almost all those we interviewed for this study wereengaged in various kinds of secondary prevention work with older people. Much"risk assessment" takes place within a person’s home and is notonly concerned with falls, but invariably involves people who have a particularhealth or social problem which has brought them to the attention of theprofessional group. While this group invariably regard their falls asunpreventable, medical events there is likely to be potential for intervention.Falls are perceived to be devastating "the worst thing" and mostolder people who have had such an event do not wish to become dependent as aresult. The scope for primary prevention on the part of professional groupssuch as physiotherapists, occupational therapists and podiatrists may,therefore, be quite limited. Our data suggest that people may be more receptiveto messages around prevention when they have actually had a fall or near-fall.

What the data do indicate is that older people –particularly those at younger ages – are quite resistant to attempts todefine them as either old or "at risk". Indeed, the definition of thetarget groups may have to be considered with care: is it appropriate to targethealth promotion at populations or groups defined merely in terms of age?Supporting healthy ageing may be a much more productive approach than promotinga healthy old age. Previous research, which has explored older people’sperceptions of exercise, indicates that the social rather than healthbenefits of exercise were what people actually valued (Stead et al, 1997).Finding ways to enhance confidence, social activity and promote independencemay be particularly effective in facilitating change among those groups forwhom falls are perceived to be merely a distant future risk.

More than anything, the data gathered here indicate thathealth education campaigns to prevent "falls in older people" areunlikely to succeed.

6.1 The validation of generalised constructs

The aim of the second stage of data-collection was,primarily, to explore further the general constructs which had emerged from thefirst phase of the study. In addition, this element of the study was intendedto raise and explore issues which might have clear implications for healthpromotion – both in relation to falls, but also in relation to healthpromotion work with older people.

Although some of the narratives were, perhaps, moreconstrained by the approach we used which had explicitly focussed discussion onkey issues, we had a strong sense that the "constructs" derived inthe first stage were confirmed in this second stage. In particular, respondentsmade similar distinctions – both conceptually and linguistically betweendifferent kinds of falling events; falls and fallers were similarly imbued withnegative connotations and, for the younger elderly in particular were perceivedas a distant threat which did not impinge on them. Old age was invariablydefined as a state of mind – until or if, that is, illness or healthproblems intervened. Feeling young was associated by respondents with having anactive mind and body, being independent, and having "interests".These were more often perceived as the routes to good health than, say, takingup formal exercise. Insofar as exercise was seen to be important, it was oftenwithin the broader context of the social contacts which might accompany suchendeavours. To some extent, taking up exercise or a sport was merely a way ofmeeting up with other people. Urban living can be as hazardous as rural living:pavements can be bad anywhere. The differences we had observed between Asianand non-Asian elders in terms of perspectives on ageing and risk were broadlyconfirmed – not least by the need to recruit from Asian elders at youngerages. Our efforts to validate earlier concepts were hampered, however, by thedifficulties in the second stage of gathering qualitative data using non-nativespeakers, and the related difficulties of translating and interpreting subtlenuances of meaning and emphasis.

This final chapter attempts to put these data into a broaderperspective. What started as a study of lay and professional constructions ofrisks of falling in older age in relation to the primary prevention of fallsbecame more complex. The material gathered has some quite profound implicationsfor the development any primary prevention strategies, but raises very realdifficulties for any such attempts. There is a broad consensus within healthpromotion that interventions must be grounded in the everyday experiences ofthe "target" group: without that focus, any intervention is likely tofail (Killoran et al, 1997). Health promotion work with older people in generaland in relation to falls prevention, in particular, has largely lacked that layfocus (Oakley et al, 1995) and this study, therefore, potentially fills a realgap in understanding. The focus for this final chapter is primarily on theimplications of this study for health promotion – specifically in relationto the primary prevention of falls, but also more generally in relation to workwith older people.

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Appendices

Appendix 2. The use of quotes from Phase 1 to explore key constructs

Quote	Language offalls	Perceptionsof falls	Perceptionsof risk	Definingolder age	Health in older age	Social &cultural perspectives	Definition offalls	Attributionof falls	Prevention offalls
A trip’s not so bad as a fall	X	X					X	X
I think if I saw somebody fall I would help them.		X						X
I don’t think people fall just because they are older	X	X	X		X		X	X	X
You lose your balance easier as you get older			X		X			X
You’ve got to try and be as independent as possible				X		X			X
The definition of someone old is someone who feels old			X	X		X	X
It’s not so much the fear of falling..it’s the Embarrassment of having to get other people to help them		X					X	X
There’s nothing really you can change about falling. It’sjust one of these things that suddenly happens	X		X					X	X
Once you are old.. you just have to be extra careful and thinkcarefully about what you can do easily and not take any risks			X	X		X			X
Did she really stumble or was it mentally a blackout?		X						X
Folk that have never done any exercise will be old before theirtime			X		X				X
If I need a light bulb changed I wait for someone to come and doit			X						X
Falling is the worst thing that can happen to you	X	X					X

Appendix 3. The lay and professional participants

Phase 1 lay participants

Lay Group 1	Active males
Lay Group 2	Frail elders (female)
Lay Group 3	Active females
Lay Group 4	General elders (female)
Lay Group 5	Asian elders (mixed sex)
Lay Interview 1	Frail (female)
Lay Interview 2	General elder, female
Lay Interview 3	General elder, female
Lay Interview 4	Active female
Lay Interview 5	Active male
Lay Interview 6	Frail (female)
Lay Interview 7	Asian (female)
Lay Interview 8	Asian (female)
Lay Interview 9	Asian (male)

Phase 1 professional participants

Professional Group 1	Community Rehabilitation Team (NHSTrust)
Professional Group 2	Community Chiropody Team (NHS Trust)
Professional Group 3	Community Nurses (NHS Trust)
Professional Interview 1	Care and Repair Services Manager,Age Concern
Professional Interview 2	Home Care Services Manager (LocalAuthority)
Professional Interview 3	General Practitioner
Professional Interview 5	Occupational Therapist (LocalAuthority)
Professional Interview 6	Physiotherapy Services Manager (NHSTrust)
Professional Interview 7	Community Physiotherapist (NHSTrust)
Professional Interview 8	Development Worker, Age Concern
Professional Interview 9	Chiropody Services Manager (NHSTrust)

Phase 2 lay participants

Focus group 1	Edinburgh, Sheltered Housing Residents
Focus group 2	Edinburgh, Social Club members
Focus group 3	Edinburgh, Social Club members
Focus group 4	Edinburgh, Asian elders
Focus group 5	Borders, Over 60s Club members
Focus group 6	Borders, Badmington Club members
Focus group 7	Borders, Carpet Bowls Club members
Focus group 8	Borders, Exercise Club members
Focus group 9	Borders, Over 60s Club members
Focus group 10	Edinburgh, Lunch Club members

Appendix 1. Interview Guide for Phase 1 Individual and Group Interviews

Layinterviews

[a] Biographical and background information:

The aim of these initial questions is to put respondents attheir ease, establish rapport, and gather basic information about therespondent and his/her life and to provide a context for the rest of theinterview:

• respondent's age
• whether works/worked/occupation
• who lives with
• life changes/death of spouse
• children/grandchildren/own parent/s alive
• contacts with friends: how often sees friends, whatkinds of things do
• contacts with family: how often seen, involvement inown life
• any health problems or difficulties (eg deafness,problems with eyes)
• current medication - prescribed and non-prescribed
• use of services - home help/cleaner/day centres/helpwith daily living

[b] Perceptions of ageing andrisk

We are interested here in whether respondents feel thatolder people, in general, are more likely to fall or hurt themselves, to whatextent they put themselves in the category of an "older person" whomight be at risk of falling, who or what "kind" of person they thinkdoes have falls, how this affects how they feel and behave, what priority (ifany) is given to trying to minimise risks of falling/ accidents/ injury, and towhat extent falling is viewed as a risk compared with other"dangers".

Do older people fall/hurt themselves/have more accidents?
Who does fall?
Is falling something that happens to other or older peoplethan themselves? What kind of people fall? What do they think about olderpeople who have falls?
Is falling something that people think or worry about inrelation to themselves or others?
Are there ways in which people feel their bodies "letthem down" or do not function as well as before? In what ways?
Do they feel differently about what and how they do thingscompared with when they were younger; as confident?
Do respondents do anything differently as they have gotolder to minimise risks? What risks? When started doing things differently?What, if anything, prompted changes?
What do they think/feel/believe are the main risks facingolder people

[c] Respondents' experiences andperceptions

We are interested here in eliciting reports relating torespondents' experiences of falling and near falls: how it is perceived anddescribed. Again, it is likely that personal experiences will already haveemerged. The important issue is to gather as much information as possible aboutany falling-type events, listening carefully to the language used andemotional responses and consequences. Probe to establish what happenedwhen respondent (or person they know) had "fall", including externalfactors which are mentioned - such as lighting, repair of pavements etc. Respondents may be unwilling to talk about their own experiences (or may nothave had a fall) but are happier (or able)to talk about someone else'sexperience of falling - including, for example, their own parents. Inthe group interviews, the issue must be raised especially carefully as peoplemay not want to admit to a fall in front of others.

Has respondent (or someone they know) ever had incident inwhich they have not remained on feet/sitting: what happened, when did ithappen, where was respondent at time, what doing at time - something alwaysdone/ routine/ something new, any idea of why accident occurred, was it a fall?what made it a "fall"? why not "a fall", how felt attime...and later...and now - , how affected respondent - feelings/ changes inbehaviour since, family involvement/interference, professional involvement -who, when, what feels about, ever happened again - gather details of all"falls"

Whether worries about falling: why - fear ofintervention/loss of independence, whether sees self as at risk of falling -why/why not, how thinks falls affect people, are any worries about fallinglinked to actual experiences of falls?

Whether believes falls be prevented - how, why not

Professional interviews

The individual interviews are largely with professionalswith a managerial or strategic role within their organisation, whereas thegroup interviews are with practitioners within particular disciplines. The aimof these interviews is to elicit perceptions of falls in older people: what isa "fall", who falls, in what circumstances, what are the causes offalls, how do fallers and potential fallers come to the attention of health andother professionals, what criteria or guidelines influence the assessment ofolder people's need for intervention in relation to fall, and/or rehabilitationor care following a fall, are falls preventable, and what role, if any, doestheir discipline/professional group have (or could or should have) in relationto the prevention of falls in older people. As in the lay interviews, itis important to listen to the language used and to explore different uses ofterms.

If any assessment forms and/or there are written guidelinesrelating to the assessment, prevention or rehabilitation of falls/fallers,please ask for copies.

Are older people more likely to fall? Is this a"problem"? Why?
What does respondents regard as a fall - are there differentkinds of falls, and do professionals distinguish between differentkinds/categories of fall (how/what), and if so - does this affect responses
What they regard to be the key causes of falls in olderpeople
Are the causes of falls any different from falls in youngerpeople? In what ways? or why not?
Who (or what kind of person) regard as likely to fall or beat risk of a fall,
Are there situations or circumstances which increaselikelihood of falls
How is risk of falling actually assessed by professionalgroup - is it solely in relation to falls or is it more general? How is thisoperationalised in individual cases (group interviews only?) How is assessmentcarried out? And, by whom? What happens after assessment?
What determined which professionals are involved?
What (initially) usually brings someone to the attention ofprofessionals?
Do potential fallers (i.e. people who have not yet had afall) come to the attention of professionals as potential fallers or for otherreasons?
What makes someone a "potential faller"?
Do they believe that falls can be prevented? If so, how? Forwhom (what kind of person/situation) can falls be prevented? If not, why not?
Is prevention relevant only in relation to first falls oronly recurrent/ subsequent falls? Why(not)?