How socioeconomic status affects fall risk

Posted November 4, 2015

As the days grow cold and grey and the evenings fall dark faster than the leaves plummeting in droves from the giant tree in my backyard, my focus and time shifts inside to my humble home sweet home. As the calendar leads us into full autumn mode I can be found hovering over the fragrant steam emanating off a fresh pot of soup (last night was African Peanut Stew), curled up with the dog enjoying a good book or rotating the selection in my closet from sundresses and sandals to leggings, sweaters and tall warm boots. Unfortunately for many older adults though, due to a complex array of factors called the social determinants of health (SDOH), home can be much more a hazard than a haven.

Evidence has long shown a distinct relationship between SDOH and many health conditions and outcomes but recently researchers and practitioners continue to highlight the link between SDOH, socio-economic status (SES) in particular, and injury. Indicators of SES include income, education, housing, occupation and ethnicity. Those saddled with the burden of poverty bear the greatest burden of injury in Canada. The Canadian Institute for Health Information (CIHI) reports that the poorest Canadians experience injury at a rate 1.3 times higher than the wealthiest. The highest rates of hospitalizations for falls for adults over 45 were experienced by those living in the least affluent neighbourhoods (CIHI, 2010).

Many of our best practice recommendations for reducing falls focus on the home environment. Clients living in poverty often experience insecure or inadequate housing making them vulnerable to hazards associated with injury. However many of the interventions to reduce home hazards assume a client's independent financial ability to implement the intervention and control over the hazard. A client with a low income and living in rented or shared accommodations may have little to no direct control over hazards such as:

insufficient lighting,

lack of safety features such as grab bars & non-slip surfaces in bathrooms,

inadequate maintenance or repair, and

common areas such as stairways, foyers and hallways with poor design and insufficient safety features.

Additionally low income presents a barrier to accessing items to reduce personal fall risk factors:

clothing (e.g. dedicated and specialized footwear for home/winter/physical activity, clothing that is properly fitted)

eyeglasses and sunglasses

assistive devices (e.g. canes, walkers)

proper nutrition

exercise and education classes

The connection between poverty, falls and residential hazards associated with injury highlights the need for targeted efforts to prevent falls among our most vulnerable citizens. The following recommendations can help you begin to address SES-related barriers to home safety for your clients.

RECOMMENDATION	RATIONALE	EXAMPLE
Screening for poverty	Recently developed clinical tools to assess for poverty in a primary care setting can help you to identify your client’s unique income-related risks and barriers to implementing your recommendations.	This tool provides steps to screen for poverty, adjust risk and intervene in a primary care setting. Income referral resources are included. 4 Pages.
Partnerships	Collaboration and coordination with health care and community service providers is vital to identify and close gaps between services and build strong referral pathways.	Provide a referral to an occupational therapist. An OT may be able to perform an in-home assessment to identify and reduce your client’s barriers to home safety by connecting them to low or no-cost home modification options or services and assistive devices.
Targeted programs and services	Research strongly suggests that programs, services and other actions that target prevention of falls and reduce disparities in income would have the most potential benefit. According to Cubbin & Smith “Without access to information and resources tailored to their needs, low SES individuals are less likely to believe that injuries are preventable ... and are less likely to practice effective injury prevention measures”.	Work closely with primary care providers to support referrals of these high risk clients to your falls prevention program. Actively engage community members in the planning of programs & services to identify and reduce barriers to their participation (ie transportation, cost, location, language) and to tailor content to their needs. Special attention should be given to identifying and assisting those living in isolation. Develop an SDOH team in your practice to help clients address the critical issues
Education and action	Education is an important part of fall prevention but on its own is not effective. Programs and services must go beyond education in order to be effective, helping to reduce barriers to applying gained knowledge.	Ensure that your educational programs and other efforts include a multi-modal approach ie distribute safety equipment or provide other incentives for use of safety equipment as part of your educational program; Implement a home visiting program that includes an educational component. Understand and provide support for completion of social assistance forms.

References:

Canadian Institute for Health Information. (2010). Injury hospitalizations and socioeconomic status. Ottawa: Canadian Institute for Health Information.

Cubbin, C., Smith, G. (2002). Socioeconomic inequalities in injury: Critical issues in design and analysis. Annual Review of Public Health 23:349-75.

Laflamme, L., Burrows, S., Hasselberg, M. (2009). Socioeconomic differences in injury risks: A review of findings and a discussion of potential countermeasures. World Health Organization Europe.

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