ABSTRACT
Objective:
to assess the effectiveness of using an educational video in comparison withverbal nursing guidelines in increasing older adults’ perception of fallingrisks.
Method:
this is a randomized clinical trial in a cluster, with 138 community olderadults, randomized into an intervention group, which watched an educationalvideo, and a control group, which received verbal instructions. Theperception of falling risks was assessed by FRAQ-Brazil in the pre-test andafter a 30-day follow-up. Student’s t-test was used for dependent samples tocompare intragroup means and for independent samples to compare intergroupmeans. The effect size was determined by Cohen’s d.
Results:
in the intragroup analysis, intervention and control groups had an increasein perception, with a statistically significant difference between pre-andpost-tests. In the intergroup analysis, the control group showed a greaterincrease in the perception of falling risks in relation to the interventiongroup (p = 0.013), with Cohen’s d of small effect.
Conclusion:
the use of an educational video and verbal instructions increased olderadults’ perception of falling risks, with better results in the controlgroup. However, the effect size was small. RBR-8nfggd.
DESCRIPTORS: Aged, Accidental Falls, Health Education, Instructional Film and Video, Geriatric Nursing, Clinical Trial
INTRODUCTION
Falls are an important external cause of morbidity and mortality in older adultspopulation worldwide, and fall prevention is one of the main challenges amonghealth professionals and researchers in the areas of gerontology andgeriatrics(1–2). These accidents are a result of asynergistic interaction of biological, socioeconomic, environmental and behavioralfactors(3). Thus,preventive interventions should consider the multifactorial nature of thisproblem.
The World Health Organization (WHO) model for fall prevention in old age proposes anaction plan, which points out the importance of increasing awareness about theprevention of these accidents, improving risk assessment and implementinginterventions(3). Thus,strategies to cope with falls in older adults should promote the empowerment of thispopulation, in order to increase the perception of the risks to which they areexposed(4).
The perception of risk can be understood as the interpretation or understanding of aperson at each dangerous event or specific threat(5). Regarding older adults’ perception about fallingrisks, studies conducted in Australia and Brazil revealed that most of thispopulation underestimates or does not recognize their vulnerability to thisaccident(6–7). In this context, nurses have a strategic role inpreventing falls and increasing this perception in older adults, as they areinserted in the various levels of geriatric care, acting in awareness and behaviorchange, especially through health education, employed especially in verbalguidelines in Primary Health Care (PHC)(8). In the field of health education, the technical-scientificadvancement provided the advent of educational technologies, which have beenincorporated into nursing performance as teaching tools in health(9–10).
Among the educational technologies for community older adults, identified in anintegrative review, the educational video emerged as a tool that promotedimprovement of different outcomes in experiments with this audience. Moreover, itsuse was effective in different aspects related to falls, such as identification andreduction of risks, level of motivation for self-care and knowledge to preventdangerous behaviors(11). Thus, theeducational video is presented as a technological instrument, which allows usingsimultaneous and playful resources, providing the standardization of instructionsand conveying of information to a greater number of people at the sametime(12–13).
Therefore, it was established as a hypothesis that the use of educational video iseffective in increasing older adults’ perception about falling risks, compared toverbal nursing guidelines. However, although this technology is presented as aresource to provide the health education process with the necessary tools, there isno evidence in the literature about its effects on older adults’ perception aboutfalling risks in the Brazilian reality. Therefore, it is necessary to provideevidence that addresses this knowledge gap, with a view to contributing to providingthe health education process with older adults in nurses’ practice with thenecessary tools, especially in PHC. From this, this study aimed to assess theeffectiveness of using an educational video compared to verbal nursing guidelines inincreasing older adults’ perception about falling risks.
METHOD
Design of Study
This is a randomized clustered controlled clinical trial with two parallelgroups, with 1:1 allocation rate, conducted from May to September 2019. For thestudy report, the Consolidated of Reporting Trials (consort) for RandomizedTrials of Nonpharmacological Treatments(14) was used.
Population
The population consisted of 1,773 older adults aged 65 years and older,registered in the urban area of PHC, in the city of Bom Jesus, PI, Brazil.
Local
The data collection site was the Basic Health Unit (BHU) of each of the nineFamily Health Strategy (FHS) teams of the city urban area.
Selection Criteria
Participants with age equal to or greater than 65 years, without cognitiveimpairment, assessed by the Mini Mental State Examination (MMSE), with cut-offpoints defined from education(15), not presenting physical impossibility of locomotion tothe BHU were included. Participants planning to move to another city before thedata collection completion period, presenting hearing, visual or speechimpairments – these conditions were verified through the information obtainedfrom the unit’s Community Health Worker (CHW) and nurse – were excluded. Peoplecould be discontinued from the study if they did not return to the BHU or werenot located for post-test assessment.
Sample Definition
The sample size definition was based on the equation for comparison between twogroups, 95% confidence level, 80% test power and 25% expected clinicaldifference, based on a previous study(7). The calculations indicated a minimum sample of 56older adults in each group, totaling 112. When considering the possible losses,50% of this total was added, so it was necessary to recruit at least 168 olderadults.
Data Collection
The primary outcome of interest was the mean perceived risk of falling, and thesecondary outcome was the percentage of correct answers for the questionnaireitems. For data collection, two instruments were used: the Fall Risk PerceptionQuestionnaire (FRAQ-Brazil)(4)and a script to characterize demographic, clinical and fall data.
The FRAQ-Brazil was used to assess the outcomes of this study. This instrumentwas developed by Canadian researchers and presented construct validity andreasonable test-retest reliability. In the present study, the FRAQ-Brazil wasused, which has semantic, idiomatic, cultural and conceptual equivalences forolder adults aged 65 years and over, internal consistency, with Cronbach’s Alphaof 0.95, intra-examiner equivalence with a Kappa coefficient of 0.89 andinter-examiner of 0.78. The instrument is divided into two parts: the first(part A) has two open-ended questions, which investigate the prior knowledge ofolder adults about the causes of falls and how they obtained this information,and a closed-ended question, on the opinion of older adults regarding thepossibility of being susceptible to fall at any time; the second (part B)consists of 25 multiple-choice questions about fall risks. The final score isobtained from the sum of the number of correct answers, indicated in thequestions in part B. All questions had only one correct alternative. However, aquestion contained eight correct answers and for each correct answer a point isassigned, so that the FRAQ-Brazil score varies from zero to 32 and the greaterthe number of points, the better the perception of fall risks(4).
A script was prepared by the members of the Study Group on Aging and ExternalCauses of Morbidity and Mortality (GEECEM – Grupo de Estudos emEnvelhecimento e Causas Externas de Morbimortalidade) of theUniversidade Federal do Piauí (UFPI) and submitted tovalidation by five judges, experts in gerontology and geriatrics. An adaptedversion with questions was used to collect sociodemographic (sex, age, readingand writing, years of study and family composition), economic (family income),clinical (physical exercise) and fall (fall in the last year) data.
Prior to the start of the interventions, participants were randomized into theirrespective groups. To reduce the risk of sample contamination, through contactbetween participants in the intervention group (IG) and control group (CG),cluster randomization was chosen, so that the clusters corresponded to the FHSteams and their coverage area. Of the nine health teams, one was previouslydrawn to conduct the pilot study and was not part of the final sample. Thus,eight teams corresponded to the clusters that were randomized by simple randomallocation of 1:1, in parallel groups, of which four teams composed the IG andanother four the CG. Randomization was performed using the R by a professionalwho did not participate in data collection. To define the random sequence, alist of teams was organized, starting in the ascending order of their respectiveregistration numbers in FHS. When considering the numerical sequence generatedby R, which defined IG and CG, the teams were allocated. The number ofparticipants in each cluster was defined equitably and proportionally to thenumber of older adults aged 65 and over registered in each health team.
A pilot study was conducted, from May to June 2019, to test the feasibility ofrecruiting the sample, the time demand needed to apply the instruments, promotethe setting and improve the interventions. Participants were 18 older adultsregistered in the previously selected FHS team. In this stage, the fourmicro-areas of the team were the clusters, randomized by simple randomallocation into two groups, which constituted the IG and CG, with nine olderadults in each. The pilot study followed the entire clinical trialmethodological operationalization and its participants did not make up the finalstudy sample. There was no change in data collection procedures after a pilotstudy. However, the team of pre-test interviewers was expanded for the clinicaltrial.
The final team of 15 interviewers was formed by nursing professors and nursingstudents from UFPI. The interviewers were divided into two teams: the first,with nine interviewers, to apply the instruments in the pre-test of IG and CG;the second, with six other interviewers, to apply the questionnaire in the IGand CG post-test. The two teams were trained by the main researcher at differenttimes. The recruitment and follow-up period took place from June to August 2019,with the participants, from IG and CG, organized into subgroups of up to tenolder adults. The operationalization of data collection occurred equally in IGand CG, in two stages, with only the difference in the intervention applied.
(1) First stage: data collection was scheduled in each BHU andthe unit nurse was asked to list potentially eligible older adults in the areacovered by the health team, based on the inclusion criteria. Based on thisindication, a draw was carried out to define the participants of each team by aprofessional who did not participate in the data collection. The randomlyselected older adults were invited on a home visit by the CHW, attended the BHUand, after accepting to participate in the research, signed the Informed ConsentForm (ICF). In cases of illiteracy, the ICF was read to older adults and awitness, and the fingerprint of participants’ thumb was collected.
Then, in an individual interview in a private place of BHU, MMSE was applied anddata were collected for characterization. Moreover, a pre-test assessment of theperception of fall risks was carried out using the FRAQ-Brazil. Soon after,participants were sent to the BHU meeting room for group educational activity.In both the IG and the CG, older adults were accommodated in chairs, arrangedequidistantly in a semicircle.
The IG watched an educational video entitled “Risco de queda: não caianessa”, which was constructed based on the Cognitive Theory ofMultimedia Learning and selected content based on the WHO fall prevention modeland FRAQ-Brazil items. It had a digital animation format, audio narration,duration of ten minutes and five seconds and contemplated biological,socioeconomic, environmental and behavioral risks of falls in older adults. Thevideo was validated by nurses with expertise in geriatrics, gerontology andfalls and assessed by older adults(16). The intervention was conducted by a nurse, who didnot compose the team of interviewers. The video was projected on a white wall,through a multimedia projector and audio transmitted by a speaker with Rms 80wpower and a frequency of 100 Hz – KHz, displayed only once, without pause orrepetition, and no questions were answered, in order not to influence theassessment of study outcomes. At the end, older adults were invited to return 30days later for post-test assessment.
The CG received verbal guidance on fall risk in older adults by a nursepreviously trained by the main researcher and who was not part of the team ofinterviewers. For this study, a Standard Operating Procedure (SOP) was built topromote the standardization of exposures to all subgroups of ten older adults.The SOP contained a procedure definition, necessary materials, personalpresentation, environment organization, and content about falling risks,addressed in the same sequence presented in the video. In order to guide thenurse and ensure standardization of information in all subgroups, a 150 × 90 cmposter was constructed, which contained reminders of all SOP topics (Figure 1).
The poster was fixed on the wall located behind the row of chairs in which olderadults were accommodated and in front of a nurse, so that participants could notsee it. The nurse positioned herself in the center of the semicircle and did notpresent any teaching material, such as images or videos. Thus, there was onlyoral exposure. Exposure time in the subgroups ranged from 25 to 30 minutes. Atthe end, older adults were also invited to return 30 days later for post-testassessment.
(2) Second stage: an interview was conducted for post-testassessment of the perception of fall risks by FRAQ-Brazil, 30 days after thefirst stage, at the BHU. The CHW reinforced the invitation up to two daysbefore the scheduled date. Older adults who did not attend were contacted bytelephone to schedule an interview, or received up to three home visit attemptsto locate and fill out the instrument.
Blinding was not possible to be applied to the IG and CG older adults, since theyknew the intervention to which they were submitted, as well as the pre-testresearch team and the researchers who conducted the groups. Blinding was appliedto the post-test interviewees in both groups, as they did not know theintervention applied to each participant and did not receive information on theprocedures previously adopted. Also, throughout the process of tabulation anddata processing, the professional responsible for statistical analysis wasblinded, through group coding, in G1 and G2, in the database.
Data Analysis and Treatment
Data were analyzed in the Statistical Package for the Social Sciences, version21.0. Compliance with the normal distribution of numerical variables wasverified by the Kolmogorov-Smirnov test. From the characteristics of eachvariable, statistical tests were determined. A 5% significance level wasconsidered, and the principles of analysis per protocol were followed.Categorical variables were described as absolute and relative frequencies, andnumerical variables, as mean and standard deviation or median and interquartilerange. The group homogeneity was tested by applying Student’s t-test forindependent samples, Mann-Whitney U test and Chi-square test for proportion.
To compare the proportions of correct answers of FRAQ-Brazil items betweengroups, the chi-square test for proportion and Fisher’s exact test were adopted.The effect of the interventions was assessed by comparing the means of the finalFRAQ-Brazil score of intra-and inter-group participants, using Student’s t-testfor dependent and Student’s t-test for independent samples, respectively. Theeffect size was established by Cohen’s d and classified as negligible(<0.19), small (0.20–0.49), medium (0.50–0.79) or large(0.80–1.29)(17).
Ethical Aspects
The study complied with Resolution 466/12 of the Brazilian National HealthCouncil (Conselho Nacional de Saúde). It was approved by theResearch Ethics Committee of UFPI in 2019, under Opinion 3.334.943, andregistered in the Brazilian Clinical Trials Registry database, with primaryidentifier: RBR-8nfggd.
RESULTS
During the study period, 174 older adults were recruited to assess eligibility. Only160 met the inclusion criteria and were allocated to the respective groups. In the30-day follow-up there was a loss of 22 older adults, so 138 completed the study (IG= 69; CG = 69) (Figure 2). The reason for thelosses was related to the discontinuity criteria.
Most participants were female (66.7%), aged 65 to 79 years (81.9%), with a mean ageof 73.5 years (SD = 6.2), unable to read and write (53.6%), with a median of oneyear of study (IR = 0–3), median family composition of two people (IR = 1–4) andmedian monthly family income of 1,996.00 (IR = 998.00–1,996.00), considering theminimum wage of Brazil in 2019 (R$998.00 – about US$184.81). It was found that mostolder adults practiced physical exercise (55.8%), had not suffered a fall in thelast year (61.6%), felt that they were at risk of falling at any time (63.8%) andhad not received information about fall risks (83.3%). Those who received theseguidelines reported having been guided by CHWs (66.2%), nurses (40.0%), physicians(33.0%), television (30.8%), social worker (10.0%), nursing students (10.0%) and onecould not inform which professional (10.0%). IG and CG were homogeneous at baseline,in relation to sociodemographic, clinical and fall variables (p > 0.05) (Table 1).
Table 1. Distribution of sociodemographic, economic, clinical and fallcharacteristics of 138 older adults according to intervention and controlgroups – Bom Jesus, PI, Brazil, 2019.
Categorical variables | Intervention group (n =69) | Control group (n =69) | p | |||
---|---|---|---|---|---|---|
n (%) | n (%) | |||||
Sex | ||||||
Male | 22 (31.9) | 24 (34.8) | 0.718* | |||
Female | 47 (68.1) | 45 (65.2) | ||||
Age group | ||||||
65 to 79 years | 55 (79.7) | 58 (84.1) | 0.507* | |||
≥80 years | 14 (20.3) | 11 (15.9) | ||||
Read and write | ||||||
Yes | 32 (46.4) | 32 (46.4) | 1.000* | |||
No | 37 (53.6) | 37 (53.6) | ||||
Physical exercise | ||||||
Yes | 37 (53.6) | 40 (58.0) | 0.607* | |||
No | 32 (46.4) | 29 (42.0) | ||||
Fall in the last year | ||||||
Yes | 22 (31.9%) | 31 (44.9%) | 0.115* | |||
No | 47 (68.1%) | 38 (55.1%) | ||||
Feel at risk of falling | ||||||
Yes | 45 (65.2%) | 43 (62.3%) | 0.723* | |||
No | 24 (34.8%) | 26 (37.7%) | ||||
Received information on fall risks | ||||||
Yes | 13 (18.8%) | 10 (14.5%) | 0.647* | |||
No | 56 (81.2%) | 59 (85.5%) | ||||
Numerical variables | Mean (SD+) | Mean (SD+) | p | |||
Age (years) | 73.6 (6.4) | 73.5 (6.2) | 0.871‡ | |||
Median (IR§) | Median (IR§) | p | ||||
Education (years) | 0 (0–4) | 1 (0–3) | 0.817|| | |||
Family composition | 2 (1–4) | 2 (1–3.5) | 0.821|| | |||
Family income | 1996 (998–1996) | 1996 (998–1996) | 0.244|| |
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*Chi-square test; †SD = standard deviation;‡Student’s t-test for independent samples; §IR =Interquartile range; ||Mann-Whitney U test;¶Current minimum wage = R$998.00, Brazil, 2019.
Regarding the FRAQ-Brazil scores in the pre-test, there was no statisticallysignificant difference between IG and CG. There was a statistically significantincrease in the mean scores between pre-and post-tests, both in IG and in CG.However, the mean difference between the two moments was higher in CG. The mean ofFRAQ-Brazil scores, verified in the post-test in CG, presented a higher value thanthe mean of IG. Despite the statistically significant differences observed in thecomparison between groups, the effect size of using an educational video, incomparison with the verbal nursing guidelines on older adults’ perception aboutfalling risks, from Cohen’s d, was small to be considered clinically important(Table 2). There was no report ofparticipants about damage or unwanted effects from the interventions.
Table 2. Intra-group and inter-group comparison of the mean FRAQ-Brazil scores ofthe 138 study participants and effect size – Bom Jesus, PI, Brazil,2019.
Group | Pre-test | Post-test | p‡ | Difference | |||
---|---|---|---|---|---|---|---|
Mean (SD*) | 95%† CI | Mean (SD*) | 95%† CI | Mean (SD*) | 95%† CI | ||
Intervention group | 19.2 (3.5) | 18.3–20.0 | 21.7 (2.7) | 21.0–22.4 | 0.001 | 2.5 (3.6) | 1.7–3.4 |
Control group | 18.8 (3.7) | 17.9–19.7 | 22.8 (2.5) | 22.2–23.4 | <0.001 | 4.0 (4.3) | 3.0–5.0 |
p§ | 0.559 | 0.013 | 0.030 | ||||
d|| | 0.10 | 0.43 | 0.38 |
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*SD = standard deviation; †CI = confidence interval;‡Student’s t-test for dependent samples;§Student’s t-test for independent samples;||Cohen’d.
In the analysis of the correct answers of each item in pre-and post-tests of IG andCG, it was found that, in the pre-test, seven items (2,7,10,15,24,27,29) showed astatistically significant difference and there was a similarity of groups in thenumber of correct answers in 25 items. In the post-test, three items (3,18,29)showed a statistically significant difference, and the groups were similar withregard to the number of correct answers in 29 items, as observed in Table 3.
Table 3. Percentage of correct answers between intervention and control groups inthe items to assess older adults’ perception about fall risks in pre-andpost-tests – Bom Jesus, PI, Brazil, 2019.
Items | Pre-test | p | Post-test | p | ||
---|---|---|---|---|---|---|
Intervention group | Control group | Intervention group | Control group | |||
n (%) | n (%) | n (%) | n (%) | |||
1. People aged 65 and over are more likelyto fall than younger adults | 57 (82.6) | 64 (92.8) | 0.070* | 69 (100.0) | 66 (95.7) | 0.245† |
2. Older people can change theiractivities to prevent falls | 62 (89.9) | 53 (76.8) | 0.040* | 65 (94.2) | 65 (94.2) | 1.000† |
3. Most falls result in no effect | 1 (1.4) | 0 (0.0) | 1.000† | 3 (4.3) | 11 (15.9) | 0.024* |
4. Falls make older adults less confidentto move around | 63 (91.3) | 63 (91.3) | 1.000* | 65 (94.2) | 69 (100.0) | 0.120† |
5. Falls are more likely to happen athome | 34 (49.3) | 36 (52.2) | 0.733* | 44 (63.8) | 46 (66.7) | 0.721* |
6. Older age increases falling risks | 65 (94.2) | 63 (91.3) | 0.511* | 66 (95.7) | 67 (97.1) | 1.000† |
7. Using a correct walker does notincrease the chance of falling | 53 (76.8) | 38 (55.1) | 0.007* | 57 (82.6) | 62 (89.9) | 0.217* |
8. The safest type of footwear istennis | 17 (24.6) | 24 (34.8) | 0.192* | 32 (46.4) | 31 (44.9) | 0.864* |
9. There is a higher risk of falling whenentering and exiting the shower | 34 (49.3) | 32 (46.4) | 0.733* | 36 (52.2) | 47 (68.1) | 0.056* |
10. Lower risk of falling if living with afamily | 49 (71.0) | 59 (85.5) | 0.039* | 54 (78.3) | 61 (88.4) | 0.110* |
11. Alzheimer’s affects chances offalling | 59 (85.5) | 58 (84.1) | 0.813* | 64 (92.8) | 67 (97.1) | 0.441† |
12. Brain stroke affects chances offalling | 67 (97.1) | 64 (92.8) | 0.441† | 69 (100.0) | 69 (100.0) | –§ |
13. Deafness increases chances offalling | 42 (60.9) | 43 (62.3) | 0.861* | 54 (78.3) | 58 (84.1) | 0.384* |
14. Ear problems affect chances offalling | 61 (88.4) | 56 (81.2) | 0.236* | 64 (92.8) | 69 (100.0) | 0.058* |
15. Eating salty fries does not causefalls | 28 (40.6) | 47 (68.1) | 0.001* | 34 (49.3) | 39 (56.5) | 0.495† |
16. Use of alcohol increases fallingrisks | 69 (100.0) | 68 (98.6) | 1.000† | 69 (100.0) | 69 (100.0) | –§ |
17. Medications for anxiety worry orstress may increase chances of falling | 14 (20.3) | 23 (33.3) | 0.084* | 31 (44.9) | 30 (43.5) | 0.864* |
18. Sleeping pills may increase chances offalling | 27 (39.1) | 21 (30.4) | 0.284* | 30 (43.5) | 47 (68.1) | 0.004* |
19. Mood stabilizers may increase chancesof falling | 13 (18.8) | 9 (13.0) | 0.352* | 21 (30.4) | 17 (24.6) | 0.446* |
20. Tranquillizers that control symptomssuch as hallucination can increase chances of falling | 12 (17.4) | 15 (21.7) | 0.520* | 19 (27.5) | 19 (27.5) | 1.000* |
21. Blood pressure medications mayincrease chances of falling | 22 (31.9) | 19 (27.5) | 0.576* | 27 (39.1) | 24 (34.8) | 0.597* |
22. Pain killers may increase chances offalling | 10 (14.5) | 8 (11.6) | 0.613* | 12 (17.4) | 10 (14.5) | 0.642* |
23. Morphine pain medications may increasechances of falling | 17 (24.6) | 12 (17.4) | 0.296* | 22 (31.9) | 25 (36.2) | 0.590* |
24. Heart medications may increase chancesof falling | 21 (30.4) | 11 (15.9) | 0.044* | 25 (36.2) | 22 (31.9) | 0.590* |
25. Older adults who take severalmedications have a greater chance of falling than those who takeonly one medication | 49 (71.0) | 45 (65.2) | 0.465* | 57 (82.6) | 55 (79.7) | 0.663* |
26. Staying physically active decreaseschances of falling | 53 (76.8) | 59 (85.5) | 0.191* | 57 (82.6) | 59 (85.5) | 0.642* |
27. Getting up at night to go to thebathroom can lead to falls | 61 (88.4) | 50 (72.5) | 0.018* | 65 (94.2) | 65 (94.2) | 1.000* |
28. Sitting on the edge of the bed for aminute is the best way to get out of bed | 64 (92.8) | 59 (85.5) | 0.171* | 68 (98.6) | 67 (97.1) | 1.000* |
29. Women aged 65 and over have a greaterchance of falling | 16 (23.2) | 28 (40.6) | 0.028* | 28 (40.6) | 42 (60.9) | 0.027† |
30. There is a greater chance of beinginjured when having weak or brittle bones | 67 (97.1) | 68 (98.6) | 1.000† | 69 (100.0) | 68 (98.6) | 1.000* |
31. Fear of falling increases chances offalling | 55 (79.7) | 49 (71.0) | 0.236* | 58 (84.1) | 60 (87.0) | 0.629* |
32. Having an active dog at homecontributes to falls | 61 (88.4) | 54 (78.3) | 0.110* | 64 (92.8) | 69 (100.0) | 0.058† |
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*Chi-square test; †Fisher’s exact test;§Impossibility of performing the test due to similaritybetween groups, which made the analysis tended to zero.
DISCUSSION
The results of this study showed that both the use of educational video and verbalnursing guidelines promoted an increase in older adults’ perception about fallingrisks. Although the greatest increase was observed in CG, effect size was small whencompared to IG. Thus, the use of this technology should not compete or replace theverbal guidelines of nurses, but rather be incorporated as a strategic resource in ahealth education program to prevent falls in older adults.
The higher number of correct answers in the FRAQ-Brazil questions observed among CGolder adults supports the result of a meta-analysis, which compared the use oftechnologies, such as videos and software, with direct verbal instructions to thepatient and showed that these were preferred by this public(18). An integrative review thatinvestigated the health education process for older adults who experienced fallsconcluded that the success of this intervention is enhanced by the construction of abond, through direct assistance between professional and patient(19). In this sense, it is believedthat verbal persuasion and personal contact favored the interpersonal relationshipbetween older adults and the nurse who provided guidance on fall risks. Thus, it isassumed that these elements of communication have contributed to greater motivation,understanding of information and improvement of the outcome studied.
This idea is sustained by considering that communication influences people’s behaviorand that the social representations of older adults about care in health servicesare associated with professionals’ respect, attention and education and are relatedto conversation, explanation and interest in helping them(20–21). Thisinfluence was observed in an American study, in which older adults who participatedin an educational program, with guidance from professionals on falling risks,changed behaviors: 67% started to practice physical exercise, 95.8% identified risksof falling at home and 87.3% adapted their home(22).
Regarding the role of nurses as educators in elder health, their actions arenecessary to motivate this population to perceive the risks of falls and the needfor self-care and behavioral changes. The adoption of guiding instruments, such asthe SOP, used in this study, can contribute to this process. Thus, it is urgent thatsuch intervention be practiced and perfected by nurses, especially in the actionsdeveloped in the context of PHC to increase older adults’ perception about fallrisks.
Given the strategies available to nurses to provide the process of health educationfor older adults in the community, the video is presented as a tool that favorsbreaking the paradigm of technological exclusion of this population. Thus, the useof technologies already widely used by the young is emerging for this public.
Regarding the use of educational video, it was observed, in the intragroup analysis,an increase in the mean score of 2.5 points. Other studies, identified in anintegrative literature review, showed the improvement of different outcomes relatedto falls in older adults after the use of this type of technology. In Australia andthe United States, the use of educational video promoted improved self-perception,identification and reduction of fall risks. Moreover, in the Netherlands, it waseffective in improving communication techniques for deaf older adults, and in Japan,it was effective in increasing decision-making and changing preferences forlife-support treatment(11). Theseresults show that this technological resource is presented as a tool that can favorthe multiplication of information on fall risks to this population.
The multimedia elements used in the educational video may have contributed toimproving the outcome of this study. The Cognitive Theory of Multimedia Learning,adopted in the production of the video used in this essay, is based on thepotential in audiovisual resources to improve learning, since memory processingdoes not occur in a single way, but the sum of various stimuli (visual, auditory),and states that the construction of knowledge occurs when there is integration ofprior knowledge with new content. Furthermore, this integration occurs moreeffectively through simultaneous stimulation with visual and verbal content.Therefore, the theory points out 12 principles that guide the multimedia planningand elaboration: coherence; signaling; redundancy; spatial contiguity; temporalcontiguity; segmentation; pre-training; modality; multimedia; personalization;voice; and image(23). Thus, it isbelieved that pictorial exposure allowed to expand the understanding of theinformation that was narrated, in a way that promoted an increase in the perceptionof falling risks.
However, it should be considered that people learn in different ways and thispluralistic essence can reflect in the results of educational interventions. Changesin attitudes of older adults are related to behaviors and life routine so that theydirectly influence the way they deal with health learning processes(24). Thus, it is possible thatparticipants’ specific characteristics and preferences influence the resultsobserved in educational interventions. Thus, the diversification of teachingstrategies for older adults in the community makes it possible to achieve differentmodes of learning. In addition to this, it contributes to assisting the public indifferent realities. For instance, the video can assist cases in which there is nofeasibility of performing verbal nursing guidelines or in places where difficultaccess compromises the continuous presence of health professionals.
In the comparison of the correct answers between groups in the post-test, in eachitem of the questionnaire, there was a statistically significant difference in onlythree items, referring to the perception that most falls result in no effect (item3), sleeping pills increase the chance of falling (item 18) and older women are morelikely to fall (item 29). In these three items, the most correct answers wererecorded in CG. In the others, the groups had similar effectiveness. This showsthat, in this study, verbal nursing guidelines were superior to the use ofeducational video to generate a significant increase, specifically in theaforementioned items.
It is assumed, therefore, that this difference between groups is due to the briefpresentation to elucidate this information in the video, so that verbal guidance hasenabled greater prominence and clarity to these items. This finding may also suggestthat, since the sample size was calculated to provide appropriate statistical powerto detect differences in the primary outcome, it is likely that the statisticalpower achieved was not sufficient to detect greater differences in the secondaryoutcome. Possibly, a study with a larger sample size would be necessary to detectgreater differences in the perception of each risk investigated by thequestionnaire.
This study is a pioneer in Brazil, since it fills a knowledge gap and has importantimplications for nurses’ practice in accessible and low-cost interventions. Althoughcomparing the two interventions, the effect size was small, there was an increase inolder adults’ perception about fall risk in both groups. Based on these findings,shared decision-making to select the best health education strategy should beencouraged, considering the target audience’s preferences and perspectives, as wellas nurses’ available resources and skills. It is emphasized, therefore, theimportance of this professional to program, structure and value the therapeuticmoment built during health education actions with older adults. Thus, it isimportant to emphasize the importance of investing in the permanent education fornurses to prevent falls in older adults in the community, with a view to promotingthe adoption of educational strategies based on robust scientific evidence, such asthose produced in this study. Access to the educational video, based on the widedissemination by public, private or non-governmental institutions interested in thetheme, as well as the good planning of verbal nursing guidelines, can contribute toreduce the prevalence of falls in this public.
Future studies are needed to assess the combined effect of using an educational videoand verbal nursing guidance in older adults in the community. The mechanisms bywhich there is an increase in older adults’ perception about falling risks aftereducational interventions, as well as their predictors, need to be furtherinvestigated.
The limitations of this study include only an assessment of the perception of fallingrisks after the interventions, in the follow-up period of 30 days, since theassessment in more than one moment and with a longer time interval could elucidatedifferent results. Also, due to the nature of the interventions, it was not possibleto blind the team members who conducted them and the participants. Finally, theassessment of the effect of the interventions occurred in older adults in thecommunity, Unified Health System (Sistema Único de Saúde) users,which may differ from the results obtained in interventions with institutionalizedolder adults or who are users of private health services
CONCLUSION
The use of educational video and verbal nursing guidelines increased older adults’perception about falling risks, with a statistical difference that points out betterresults in the group that received verbal guidelines. However, the effect size wassmall to be considered clinically important.
ASSOCIATE EDITOR
Marcia Regina Martins Alvarenga
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