Original Article
A self-report home environment screening tool identified older women at risk of falls

https://doi.org/10.1016/j.jclinepi.2010.02.013Get rights and content

Abstract

Objective

To evaluate a self-report version of the Home Falls and Accidents Screening Tool (HOME FAST-SR).

Study Design and Setting

The HOME FAST-SR was designed using expert review, pretesting and piloting. Agreement of self-reported home hazard ratings and ratings by health professionals was evaluated using the kappa statistic. The HOME FAST-SR was validated in a cross-sectional survey of 568 older community-living Australian women using endorsement rates for HOME FAST-SR items and the association of scores with self-reported falls.

Results

The 87-item HOME FAST-SR was constructed, and a scoring system was devised to calculate equivalent scores for the health professional version of the HOME FAST (HOME FAST-HP). Endorsement rates demonstrated that no items needed to be removed. Agreement between self-reported and professional ratings was moderate with therapists under-reporting hazards compared with older people. The mean HOME FAST score for the 568 cross-sectional participants was 9.39 (95% confidence interval: 9.1, 9.7) with a range from 2 to 23 out of a possible 25. Fallers had a significantly higher HOME FAST score (P = 0.02).

Conclusion

The HOME FAST-SR is a viable alternative to the HOME FAST-HP, and scores were associated with falls experienced by older women in a cross-sectional study.

Introduction

What is new?

Key finding

  1. A self-report assessment of the home environment is a viable option alongside tools rated by health professionals.

What this adds to what was known?
  1. Only one self-report home environmental hazard tool has been previously published. This study adds to a sparse literature on the topic and expands on the findings of the previous study by evaluating the validity of the tool in a large community sample. This article not only demonstrates that hazards can be identified in the home but also, more specifically, those hazards that are associated with the experience of falls by older people are identified.

What is the implication, what should change now?
  1. This self-report tool can be used in large-scale survey-based epidemiological research with older people. As the population is aging, there is an increasing imperative to be able to measure the home environment as a component of any community-based study on health and well-being of older people.

Falls are one of the leading causes of death, injury, and functional limitation among older people [1], [2]. Consequences of falls include injuries, fear of falling, activity limitation, and immobility [3], which can dramatically impact on quality of life experienced by older people living in the community [4]. Among the many recognized fall risk factors, the contribution of hazards in the home environment to falls risk among older people in the community has been debated [5], [6], [7], and one recent systematic review demonstrated that home modifications to reduce falls hazards (as a single intervention) were effective in preventing falls when targeted for older people who have fallen [8]. Several recent evidence-based guidelines and reviews recommend a comprehensive home hazard assessment as part of a falls prevention intervention and recommend targeting interventions to people at risk of falls [1], [9].

The measurement of home hazards is a key component in the management of falls risk for older people in the community, and appropriate tools need to be found to assist clinicians in screening for falls risk. Home hazards are frequently identified through the use of home safety checklists, many of which have established reliability and validity [10], [11], [12]. The Home Falls and Accidents Screening Tool (HOME FAST) is one measure with established psychometric properties [13], [14], [15] that is recognized as a useful clinical tool to identify environmental hazards. However, in common with existing home hazard tools, the HOME FAST is dependent on health professional ratings. Although the tool can be used by a health professional to initiate discussion with older people about reducing their falls risk, this study sought to extend the utility of the HOME FAST further by developing a self-report version to enable older people to identify their own falls risk. If a valid self-report version could be developed, there are potential benefits to health professionals in better targeting falls prevention activities in a cost-effective manner.

Self-assessment of health needs by older people and those with chronic health issues is a significant component of current policy focused on encouraging the recipients of services to be active participants in their own health care [16], [17]. Self-assessment and self-management are also consistent with current trends promoting person-centered and client-centered approaches to health professional interventions [18]. The benefits of self-assessment include allowing clients to become more aware of any actions needed to improve their health and reflecting on the services they may require, at the same time as screening clients for services more quickly and helping them to prepare for a professional assessment [19]. The use of self-report raises issues about the fundamental differences in the purpose of an assessment for health professionals and older people [20], the need for health professionals to relinquish the aspects of control over interventions, and accommodate the perceptions of their older clients [20], [21].

Several self-report tools have been validated for use with older people, such as the assessment of health status [22], physical performance after hip fracture [23], depression [24], mobility function [25], and health service use [26]. Indeed, self-reported health status remains one of the key predictors of successful aging in older people [27]. Self-reported measures and surveys with older people are frequently used in epidemiological research as a less labor-intensive method to gain health-related information from large populations of older people [28]. However, limitations in the use of self-report measures with older people have been identified for the assessment of memory [29], quality of life [30], anxiety [31], and instrumental activities of daily living [32]. Threats to the validity of self-report by older people relate to cognitive functioning, denial of disability, and difficulties with the format and practical skills needed to complete pen and paper surveys [30], [32].

There are few published self-assessments of the home environment. Morgan et al. [33] investigated the reliability of self-assessment of hazards in the homes of 52 women older than 67 years, using the Home Environment Survey Home Checklist. Good to excellent agreement between professional ratings and self-report by older people was demonstrated for most of the assessment items, with the exception of items related to clutter and access to bedroom lighting, where older women underestimated the hazard compared with trained observers. Fänge and Iwarsson [34] evaluated a self-assessment of housing environment quality designed for use with people with disabilities and older people. Results from 56 people aged 32–88 indicated good test–retest reliability and internal consistency of the instrument.

Identifying home hazards by self-report has the potential for older people to increase their awareness of the safety of their home environment at their own pace and without the authority of a health professional being involved in the process. Alternatively, identifying home hazards may lead to more immediate negative effects, such as an older person feeling more vulnerable in their home or anxious about how to resolve any hazards. However, to address the risk of hazards being undetected, an evaluation of the accuracy of self-rated identification of hazards is needed. Use of a self-report home hazard measure can also inform health professionals about the perceptions of their clients in relation to their environment. Such involvement could encourage older people to share in the process of modifying their homes with health professionals [35].

Therefore, the aims of this article are to outline the development of the self-report version of the HOME FAST (HOME FAST-SR), describe a validation of self-reported ratings compared with health professional ratings, and evaluate the capacity of the HOME FAST-SR to identify older people at risk of falls in a cross-sectional study.

Section snippets

Methods

After ethics clearance from the University of Newcastle Human Research Ethics Committee, a three-stage process was undertaken to develop the HOME FAST-SR. Participants for stages 1 and 3 of the study were older women in the older aged cohort from the Australian Longitudinal Study of Womens' Health (ALSWH), who were aged 76–81 years at the time of the study. The ALSWH participants were originally selected on a random basis from the Medicare database with an oversampling of women in rural and

Construction of the HOME FAST-SR

Of the 17 participants in the pilot study, one participant reported a fall in the previous 6 months. Sixteen out of 84 items were endorsed by more than a third of the pilot participants (n = 5). They included “not turning a light on when getting up at night” (n = 7), “not using a nonslip mat in the shower recess” (n = 10), and “having soft/deep cushions on their sitting chair” (n = 13). Using the bathtub was of particular interest as five participants indicated that they used their bathtub, one person

Discussion

The aim of this study was to evaluate the HOME FAST-SR to identify older people at risk of falls. The samples that were used to address this aim were representative of a national community sample of older women and a typical sample of clients seen by community OTs in practice. The results from the expert review, pretesting and pilot testing, suggest that content validity of the HOME FAST-SR was established, and the endorsement of the items in the community base sample confirm the results.

Conclusion

Despite some lack of agreement between self-reported and professional ratings of individual home hazard items, the HOME FAST-SR was still significantly related to self-reported falls in a community-based sample, suggesting it as a feasible tool to be used in community-based screening of home environmental falls risk. The use of self-report surveys has been criticized because of limitations, such as the potential overestimation and underestimation of self-reported ratings, especially when items

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    This study was funded by Australian Longitudinal Study of Women's Health.

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