Older men’s falls risk and confidence in completing activities of daily living: A retrospective cohort study

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Kimberley Burr 1000021400

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Older men’s falls risk and confidence in completing activities of daily living:

A retrospective cohort study

Kimberley Burr

A Project submitted in partial fulfilment of the degree Master of Occupational Therapy at Otago Polytechnic, Dunedin, New Zealand

16/12/2022

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Nau mai / Welcome

Rārangi maunga, tū te ao, tū te pō Rārangi tangata, ka matemate noa Rārangi raraunga, ka ao ka awatea

Hei oranga mō te iwi Tihei mauriora

Rows of mountains will endure time Rows of people will eventually pass on

But rows of data bring new knowledge and enlightenment For the wellbeing of all people

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Declaration of Research project being own work

Otago Polytechnic

Declaration concerning Research Project presented for the degree of Master of Occupational Therapy

I, Kimberley Burr of

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Solemnly and sincerely declare, in relation to the research Thesis/Project entitled:

Older men’s falls risk and confidence in completing activities of daily living:

A retrospective cohort study

a. that the work was done by me personally and

b. that the material has not previously been accepted in whole, or in part, for any other degree or diploma

Signature:

Date: 16^th December 2022

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4 Abstract

Background and aim: Falls are a common event that occur with ageing, with roughly one in three persons over 65 experiencing at least one fall annually. Differences in gender experiences have highlighted older women fall indoors more often and experience higher rates of injury following a fall, while older men were more likely to fall outdoors and have higher mortality rates following hospitalisation from a fall. Nevertheless, older men continue to engage in ADLs if they feel a fall is inevitable, or if they are unaware of their risk and overconfident in their ability to complete the ADLs. Additionally, older men remain underrepresented in research.

The aim of this study is to understand if there is a relationship between the clinician-assessed falls risk for older men compared to their self-assessed confidence in completing activities of daily living without falling.

Methods: A retrospective cohort study was conducted using data from 68 men aged 65 to 74.

Three clinician-assessed falls risk assessments and one self-rated assessment tool were completed by participants. The data collected from client files was analysed using descriptive statistics and Spearman’s correlation to determine the degree of the relationship. The data collected was assessed at two time points to provide more comprehensive results.

Findings: The study found more than half of older men were at risk of falls at both time points, and they rated themselves as being fairly confident when completing 14 ADLs without falling.

At time point one, there was a -.419 low negative correlation between clinician-assessed falls risk and self-assessed falls risk for older men. At time point two, there was a -.599 moderate negative relationship.

Discussions: The study findings suggest there is a relationship between older men’s ADL confidence compared to their risk of falls. Furthermore, older men were more aware of this relationship when completing complex ADLs compared to basic ADLs. With occupational therapists providing support more directed towards complex ADLs, or environmental and equipment changes to activities, this study suggests that specific activity and falls risk education should first be directed to completing basic ADLs. Further research is recommended into developing a New Zealand self-rated falls assessment as current self-rated assessment tools are not as gender specific or culturally appropriate for older men.

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Acknowledgements

“Gratitude turns what we have into enough”

Aesop

Every chapter written in this research project seemed more and more difficult to complete as I went on this journey, when in actual fact, this page of acknowledgements proved to be the most difficult as this was the last piece I was able to write before completing the thesis. A simple acknowledgement or thank you does not seem enough, but it is a good first place to start. Since starting on the Master’s pathway, I have always known the people who have brought me here, guiding me to reach this potential, possibly without even knowing it.

Firstly, thank you my supervisors, Dr Yvonne Thomas and Laura Hogue. We started this journey facing a mountain of a project, but with your guidance, this project headed in a good direction and is now completed. I have learnt an enormous amount this year and thank you both for introducing and supporting me in the field of academia. Thank you for your assistance in getting me here. Also, thank you to Dr Rita Robinson and Dr Ema Tokolahi for all of your input since I started my Bachelor’s in occupational therapy and pushing me to explore pathways in the post-graduate, Master’s (and possibly doctorate) programmes.

To my amazing husband Jean-Philippe (JP). This year has been a big one for us, starting by getting married and quickly moving on to us both completing our master’s. You were always there to help me when I needed it and encouraging me to continue giving it my all right to the very end. I am sure you will be glad for me to talk about something else now, but I can never truly express how much your support has helped me to get to the end. We have done a lot of hard work for us to both achieve our master’s goal this year, and now I am very much looking forward to seeing the best of what life has to offer with you next.

To my whanāu; parents, parent in-laws, siblings, and friends. You have all played a large role in this, something I will be forever grateful for. Some of you were brave enough to help me and read this, providing proofreading, and editing that most definitely influenced the final product. Some of you were cheerleaders, cheering me on and supporting me even at the hardest of times. Some of you even provided housing support right from the start of my study journey

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and for JP as well! Nevertheless, all of you are the reason that I have been able to achieve what I have from this. Thank you, I am truly grateful.

I have a special thank you to give to two men who may well be the reason behind my overall topic for this thesis, Jim Tango and Mathieu Wilson. Jim, you were the first occupational therapist to ever treat me like a colleague rather than a student (although I still was at the time).

During my third placement, you provided me with the opportunity to facilitate a balance programme and opened my world-view on how important the space of falls was for older persons and how much progress we still needed to make within the area. Mathieu, you were my first employer and the one who gave me the ability to become the therapist I am today. You enabled me to continue facilitating my self-developed balance class which let me continue in my passion. I truly cannot thank you both enough for what you have given me.

Lastly, but just as importantly, thank you to my workplace. You enabled me to use data to complete this project and were very gracious in the time I needed to complete this. Thank you to everyone involved.

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Chapter 2: Literature Review ... 16

2.1- Falls ... 16

2.2- Impact of ADLs as a result of falls ... 17

2.3- Older men... 19

2.3.1- Older men’s representation in research ... 19

2.3.2- Falls and ADLs for older men ... 20

2.3.3- Older men’s confidence in completing with falls risk and ADLs ... 21

2.4- The role of occupational therapy with falls and ADLs ... 22

2.5- Assessments of falls risk ... 23

2.6- Bicultural practice in New Zealand ... 26

2.7- Falls, ADLs, and men’s confidence ... 27

2.8- Summary ... 28

Chapter 3: Methodology... 29

3.1- Research methodology and suitability ... 29

3.2- Methods... 30

3.3- Sampling ... 31

3.4- Rigour ... 31

3.4.1- Reliability ... 31

3.4.2- Validity ... 32

3.5- Data collection ... 33

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3.5.1- Obtaining client files ... 33

3.5.2- Participants criteria ... 33

3.5.3- Inclusion and exclusion criteria ... 34

3.6- Ethical approval and cultural considerations ... 34

3.7- Assessment tools ... 35

3.7.1- Clinician-assessed falls risk assessments ... 36

3.7.2- Determining the overall risk of falls from clinician assessments ... 38

3.7.3- Self-assessed falls risk assessment ... 39

3.8- Statistical analysis ... 41

3.8.1- Statistical Package for Social Sciences ... 41

3.8.2- Spearman’s rho correlation ... 41

3.9- Summary ... 42

Chapter 4: Findings ... 43

4.1- Demographic data analysis ... 43

4.2- Time Point One ... 45

4.3- Falls risk: Clinician-assessed (CA-1) ... 45

4.4- Overall falls risk levels ... 46

4.5- Activities of Daily Living: Self-assessed (SA-1)... 47

4.6- Analysing participants risk levels and the mean mFES score ... 49

4.7- Conducting Spearman’s correlation analysis ... 50

4.8- Analysing overall risk level to individual Activities of Daily Living ... 51

4.9- Time Point Two ... 53

4.10- Falls risk: Clinician-assessed (CA-2)... 53

4.11- Overall falls risk levels ... 54

4.12- Activities of Daily Living; Self-assessed (SA-2) ... 55

4.13- Analysing participants risk levels and the mean mFES score ... 56

4.14- Conducting Spearman’s correlation analysis ... 58

4.15- Analysing overall risk level to individual Activities of Daily Living ... 58

4.16- Summary ... 60

Chapter 5: Discussion ... 61

5.1- Exploring the relationship ... 61

5.1.1- Awareness of falls risk ... 62

5.1.2- Overconfidence in completing ADLs ... 63

5.2- Falls assessment tools for the older male population... 65

5.3- Recommendations for the role of an occupational therapist ... 66

5.4- Influence of ethics and bicultural practice in this research ... 68

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5.5- Limitations ... 68

5.6- Recommendations of future research... 69

Chapter 6: Conclusion ... 71

Reference List ... 72

Appendices ... 90

6.1- Appendix A ... 90

6.2- Appendix B ... 92

6.3- Appendix C ... 93

6.4- Appendix D ... 94

6.5- Appendix E ... 98

6.6- Appendix F... 99

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Table of Figures

Figure 1The Timed Up and Go assessment ... 36

Figure 2 The 30-second sit to stand assessment ... 37

Figure 3The four-stage balance assessment ... 38

Figure 4Participants age... 44

Figure 5 Comparison of overall risk level and participants mean mFES scores ... 49

Figure 6 Comparison of overall risk level and participants score mFES score ... 57

Table of Tables Table 1Risk level indicators ... 39

Table 2Activities of Daily Living on the modified Falls Efficacy Scale ... 40

Table 3 Correlation coefficient scale ... 42

Table 4Ethnicity ... 45

Table 5Overall risk levels at time point one ... 47

Table 7Spearman’s correlation comparing mFES score and overall risk level ... 51

Table 8Spearman’s correlation of risk level compared to individual ADLs ... 52

Table 9Overall risk levels at time point two ... 54

Table 11Spearman’s correlation comparing mFES score and overall risk level ... 58

Table 12Spearman’s correlation of risk level compared to individual ADLs ... 59

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Abbreviations

Activities of Daily Living ADLs

Clinician-assessed falls risk CA

General Practitioner GP

Health Quality and Safety Commission New Zealand HQSNZ

modified Falls Efficacy Scale mFES

Occupational Therapy Board of New Zealand OTBNZ

Ministry of Health MoH

New Zealand NZ

Self-assessed falls risk SA

Timed Up and Go TUG

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Chapter 1: Introduction

The purpose of this study is to explore the existing literature related to falls and activities of daily living (ADLs) confidence, and to examine the relationships between clinician-assessed falls risk for older men and their self-assessed confidence in completing ADLs without falling.

This chapter will provide an introduction to the thesis main topics including; falls and older men, ADLs, and occupational therapy will be introduced, with emphasis placed on why further research is needed, before moving into the literature review where the gap in research will be demonstrated, followed by the research question for this study.

1.1- Falls and Activities of Daily Living

A fall is defined as an event where an individual inadvertently comes to rest on the ground or lower level (World Health Organization [WHO], 2022). As individuals age the likelihood of experiencing a fall increases every year, as one in three persons over 65 years old are likely to experience at least one fall annually (Cuevas-Trisan, 2019; Health Quality and Safety Commission New Zealand [HQSCNZ], 2017). With the growing elderly population in New Zealand expected to reach 30% by 2040, research is needed to inform effective falls education and supports for older persons to reduce or minimise the impact of this risk (Ministry of Health, 2004; Stats NZ, 2022b).

Activities of daily living (ADLs) can be defined as the fundamental activities that individuals perform to care for themselves daily, with two types of ADLs recognised (Mamikonian-Zarpas

& Lagana., 2015). ADLs are important to maintain with age as they enable independence and improve one’s quality of life. Basic ADLs consist of the essential activities that support an individual’s daily life such as preparing a meal, getting in and out of bed, and taking a bath or shower. There are complex ADLs that require more complex functional performances, such as gardening and using transportation (Arli et al., 2020). The specific activities identified as basic and complex ADLs vary depending on the assessment tools, however, individuals may consider an activity, such as preparing a meal, as complex rather than basic due to the physical requirements to complete the task, suggesting that the two terms of ADLs can be used loosely (Mlinac & Feng, 2016).

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A clear relationship has been established between an individual’s first fall experience and reoccurring falls, impacting ADL participation, a decline in physical function, loss of independence, and high injury rates following a fall event (Jin, 2018; Pin & Spini, 2014; Tareef, 2011). While ADLs have been researched due to the common associations between the two variables, the gender representation for males continues to be imbalanced (Thibaud et al., 2012). Research on ADLs such as gardening and transportation have been completed, but there is a lack of research pertaining to older men and the impact that falls has on their ADL confidence (Dupuis et al., 2007; Nicklett et al., 2016). This highlighted a gap for further research and influenced the development of this study’s research question.

1.2- Confidence and older men- A link to falls and ADLs

Confidence, in relation to falls, centres around an individual’s beliefs and abilities to complete ADLs without falling (Soh et al., 2021). Confidence can be measured subjectively using a rating scale, such as the modified Falls Efficacy Scale (mFES), to enable individuals an opportunity to report their beliefs of completing activities without falling, with no bias from the clinician conducting the assessment (Soh et al., 2021). Older men reported higher confidence levels in their likelihood of falling, with men in their 60’s reporting 70% less likely to be at risk of falls and 50% of men in their 70’s reporting a low risk of falls (Hughes et al., 2008). Despite numerous research available discussing falls risk, there remains an observable lack of knowledge and inclusivity regarding older men and falls. Tricco et al. (2017) conducted a review of falls prevention articles for older persons and found only 26% male participants included across 283 articles. Schoene et al. (2019) discussed fear of falling and quality of life for older persons, and similarly found 27% male participants from 30 studies totalling almost 30,000 participants.

1.3- Occupational therapy in Activities of Daily Living and falls

Occupational therapy primarily focuses on supporting individuals in four areas of ADLs that are completed regularly; play, work, leisure, and self-care. A foundational model of occupational therapy is the persons, occupation, and environment (POE) model that occupational therapists apply when working with individuals as it allows the therapist to support an individual holistically (Baptiste, 2017). The person is the client or patient that an occupational therapy aims to support, with the occupation being any area of ADLs previously mentioned; play, work, leisure, and self-care. The environment is viewed as the physical,

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social, and political space where occupations take place, and also how a person is able to perform occupations within that space (Baptiste, 2017). Occupational therapists work with individuals to ensure there is an occupational ‘fit’ in how individuals are able to perform occupations, and if there are difficulties, or a ‘mis-fit’, occupational therapists aim to address this (Hagedorn, 2000).

The use of an occupational therapy centred approach in the falls setting has shown to effectively support older persons with reducing their falls risk. A systematic review by de Connick et al.

(2017) analysed nine studies occupational therapy interventions for older persons to maintain ADLs and functional independence and found occupational therapy supports contributed to several areas of older person’s well-being, including improved mobility and function in ADL participation, improved social participation, and decreased fear of falls. Older persons maintaining ADL and functional independence was attributed to the holistic and client-centred approach that occupational therapists take when supporting older persons with ageing (de Connick et al., 2017). Applying an occupational therapist perspective on falls risk and confidence in completing ADLs is valuable persons due to the client-centred and holistic approach taken to support the overall well-being of older persons.

1.4- Research Purpose

There is a growing demand and obligation that falls research in New Zealand shifts towards gender specific research (Sandlund et al., 2017; Theobald et al., 2017). Research pertaining to the risk of falls for older men and their confidence when completing ADLs without falling could provide valuable information when approaching falls for older persons holistically.

Additionally, with the added value of an occupational therapy lens and the client centred approach, older persons are supported with maintaining activity participation, lowered risk of falls, and independence into the later stages of life.

This research aims to investigate if there is a relationship between clinician-assessed falls risk for older men compared to their self-assessed confidence in completing ADLs without falling.

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15 1.5- Research Project Structure

Chapter two of this thesis outlines a comprehensive study of the literature related to falls, ADLs, and the role of occupational therapy for older men and provides foundation for the development and conduct of an empirical study that aims to understand if there is a relationship between older men’s clinician-assessed and self-rated confidence in completing ADLs without falling.

Chapter one has provided an overview of the topics of activities of daily living, falls, and older men summarised the intent of the research. Chapter two reviews the literature on the topics previously mentioned, with comparisons and critique of research before the research question for this study is stated. Chapter three discusses the methodological approaches and explains how the data were collected and analysed. Additionally, the chapter explains ethical and cultural aspects considered before the research began. Chapter four report the findings from client files of sixty-eight men aged 65 to 74. The data on clinician-assessed risk of falls and clients self-assessed confidence in ADLs is analysed separately before being combined to answer the research question. The data is analysed at two time points to provide a more thorough outcome. Chapter five discusses findings and provides an interpretation and explanation into older men’s perceptions of their falls risk when completing basic and complex ADLs. Further discussions highlight how the assessment tools may not be gender specific or culturally appropriate to older men in New Zealand, and how the role of occupational therapy can influence future falls education. Additionally, the study’s limitations and future research recommendations are stated. Lastly, chapter six concludes the research study and how the findings contribute to a growing body of literature around falls and ADL confidence for older men.

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Chapter 2: Literature Review

This chapter outlines a systematic search for relevant literature pertaining to the topics of falls, ADLs, older men’s confidence in completing ADLs, and occupational therapy. The exploration of literature first began with the researcher identifying older men were less inclined to participate in falls prevention programmes, however, after liaising with other healthcare professionals who provided clinician-assessments of falls risk, the researcher (an occupational therapist) speculated how older men’s views were being considered in falls practice. After exploring numerous databases, the literature highlighted there was a gap between the clinical aspect of falls risk assessments and older men’s self-reports of confidence when completing ADLs without falling. This set the tone for the literature exploration which supported the establishment of the research question.

2.1- Falls

Minimising an individual’s falls risk and maintaining activities of daily living are an essential aspect to an individual’s overall well-being and can positively or negatively impact one’s quality of life, particularly in the later stages of life (Gomes et al., 2021). The physical function of well-being is a key determinant of health that enables individuals to continue participating in meaningful occupations (Abud et al., 2022). The number of older persons expressing a desire to remain independent and mobile for as long as possible is increasing, therefore it is important to provide support to older persons and encourage healthy ageing (Aspinal et al., 2016).

A falls experience for older persons is likely to occur from risk factors including decreased physical function, reduced muscle strength, pain, cognitive impairments, visual impairment, vertigo, high polypharmacy intake (use of five or more medications), increased sedentary behaviours and more (Gale et al., 2018; Nagarkar & Kulkarni, 2022; Patel et al., 2014; Seguin et al., 2012; Tareef, 2011). Individuals who experience one or more risk factors have up to a 78% chance of experiencing a fall, therefore identifying individuals’ risk of falls is important to provide falls prevention support to reduce the likelihood of falling (Tinetti & Kumar, 2010).

Literature reports that older adults who have pain experiences are likely to reduce their ADL participation by up to 80%, and up to 60% of elderly in care homes also had some forms of cognitive impairment which limited their ability to report the pain experiences resulting in reduced activity participation (Hosseini et al., 2022; Niederstrasser & Attridge, 2022).

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Falls can have significant consequences in one’s life, as a study found individuals who fell and remained on the floor for more than an hour after a fall were more likely to be hospitalised, experience serious injuries, and require long-term care support (Fleming & Brayne, 2007).

Vieria et al. (2016) ascertained that more than 90% of hip fractures occurred as a result of a fall and individuals who experienced a fall functionally declined by 35%. Furthermore, it is estimated that roughly 20% of older persons with a hip fracture following a fall pass away within a year following the fracture (Bilik et al., 2017; Panula et al., 2011). A New Zealand- based study found men were seven times more likely to pass away or require institutional care up to two years following up hip fracture compared to 1.5 times the risk for women (Fransen et al., 2002).

2.2- Impact of ADLs as a result of falls

Experiences of one or more falls often leads to a higher prevalence in difficulties with completing ADLs later in life (Sekaran et al., 2013; Stenhagen et al., 2014). Additionally, the risk of difficulties in ADL engagement in later life increased if there was any dependency in one or more areas of leisure, work, or self-cares in earlier stages of life. Older persons were found to reduce activity participation such as housework, climbing up or down stairs, and walking without aids when experiencing physical decline or appeared to be at risk of falls (Stamm et al., 2016). Additionally, when completing a difficult ADL that consisted of multiple activities, such as completing housework by walking up or down stairs to access rooms, older persons reported reduced ADL participation and were more likely to remain living in one area of the house due to the difficulties experienced (Coleman et al., 2016). Complex ADLs of shopping and managing finances were identified by A. Drummond et al. (2020) as being strongly associated with a falls event due to the physical and cognitive demands required to complete the tasks, as well as environmental factors such as uneven surfaces and time limits when crossing roads.

Older persons often may experience difficulties in completing ADLs such as getting in or out of chairs (sit-to-stand transfers), getting dressed, or activities where a push or pull demand is required (Bellettiere et al., 2015; Layec et al., 2018). Research in sedentary behaviours in older persons found men were more likely to be sedentary for almost 10 hours per day, compared to women at slightly more than 9 hours per day (Bellettiere et al., 2015). Dolecka et al. (2015) investigated seating for aged care and found that as older adults began to experience sit-to-

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stand transfer difficulties, they would implement modified strategies to stand, avoid particular seats leading to possible social exclusion, and sit for longer durations at a time. Additionally, Blackler et al. (2018) found that older adults became more reliant on external supports to complete a sit-to-stand transfer, such as the use of a wheelchair, a walking stick, or a walker.

Nagarkar and Kulkarni (2022) examined the impact of gait in addition to age, gender, and balance in relation to falls risk. The study concluded that difficulties observed in the ADLs of pushing and pulling, and the sit to stand transfers resulted in a significantly high incidence of falling. These findings were support by F. Drummond et al. (2020) who reported falls risk increased up to 41% when there were difficulties in the sit to stand transfers.

Complex activities such as gardening and using public transportation are important for sustaining participation in occupations and provide positive health benefits with ageing (Wang

& MacMillan, 2013). In New Zealand, the connection to nature and gardening is a sought-after occupation for older adults, with Freeman et al. (2019) highlighting ‘young-old’ people had more time to garden once retiring and wanted to reconnect back to nature. New Zealand Māori culture has a unique relationship to the land, referred to as ‘papatūānuku’, and supporting older adults with ageing through occupations such as gardening as a way to express occupational identity (Butcher & Breheny, 2016; Hond et al., 2019; Lockhart et al., 2019). Gardening promotes healthy ageing experiences through the occupational aspects of ‘doing’ gardening or

‘being’ in the garden environment either personally or through community connections (Scott et al., 2020). Park and Shoemaker (2009) studied posture related to gardening and identified up to 60% of gardeners experienced pain from repetitive bending. Nevertheless, adapting the biomechanical aspect of gardening to create a more supportive environment would encourage older adults to continue engaging in the occupation (Park & Shoemaker, 2009; Scott et al., 2015).

The complex ADL of transportation is also one a determinant of health through the social lens, with older adults preferring to retain their driving abilities for as long as possible as it provides a continued sense of independence and easy means of connecting with others socially (Toups et al., 2022). However, when older adults are required to stop driving, public transportation can become the primary mode of travel (Matsuda et al., 2019). An issue of using public transportation is the issue of accessibility as it may not be possible to fit external supports on the bus such as walking frames or scooters (Ravensbergen et al., 2021). A study completed for transport services in New Zealand found that older adults aged 65 to 79 would use public

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transportation more if it was easier and cheaper to access (Frith et al., 2012). Additionally, older adults reported feeling concerned by near-falls or stumbling experiences from the time pressures in transition periods when using public transportation (Morris et al., 2018).

Supporting older adults with transportation services can aid the ageing population to maintain independence and positive quality of life experiences (Lin & Cui, 2021).

Despite the knowledge of falls with ageing and impact that falls have on ADLs, minimal research has been conducted to understand if individuals are confident in completing daily activities without falling and how this is measured in relation to any clinical-based assessments of falls. More specifically, there is a considerable lack of research supporting older men in their falls risk with ageing (Liddle et al., 2017; Reid & Robson, 2007).

2.3- Older men

As humans age, a general pattern of physical decline and loss of independence may be observed, however, the ageing experience for men and women differs (Crimmins et al., 2019).

When analysing falls and ADLs with ageing, understanding the differences for both genders can provide more thorough information for how to support older persons with reducing falls risk and maintaining activity participation (Theobald et al., 2017). Assessments are available to understand how individuals feel with completing both basic and complex ADLs, although the questions or outcomes may not accurately reflect ADLs that are relevant to each gender (Edwards & Lockett., 2008; Mancini & Horak, 2010).

2.3.1- Older men’s representation in research

The inequality of gender representation in ADL research has been evident for decades. Schön et al. (2011) studied the gender differences in ADLs with declining health from 1992 to 2002.

Older men represented 39.5% of the participant sample in 1992 and 40.6% in 2002. Gustafsson et al. (2013) examined the long-term independence on ADLs for older persons from 2007 to 2011 and included a 36% male participation sample. Carmona-Torres et al. (2019) examined the difficulties in basic and complex ADLs for older persons from 2009 to 2017, with a 39.4%

male sample.

According to Stats NZ (2022a) the population of New Zealand on 30^th September 2022 was 5.1 million people, 49.6% being male and 50.4% female. Furthermore, 12.6% of the population

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are over 65, and of this, 46% are older males. When compared globally, 50.5% of the population are males and 44% of people over 65 years old are male (Country Metres, 2022).

Kerse (2014b) studied falls in New Zealand and reported 38% of women and 36% of men experienced a fall within the twelve months prior to publication. Despite the ratio of men to women globally and nationally, the research for older men in relation to falls and ADLs is not representative of their proportion of the population. Whilst some literature has argued that older women have a higher chance of falling and decline in ADLs with age (Gale et al., 2016), other research has indicated men were less likely to take preventative measures from falling, continue in ADLs despite their physical capacities, and had a higher prevalence of mortality rates following a fall (Cuevas-Trisan, 2019; Fransen et al., 2002; Liddle et al., 2019).

2.3.2- Falls and ADLs for older men

Feger et al. (2020) found that healthcare management, housework, and phone use were activities that older persons first began to experience difficulties in performing, with a 23%

male sample size. Sheehan and Tucker-Drob (2019) researched gender differences with complex ADLs and concluded older men over 50 years old had less difficulty completing ADLs but would not typically perform the activities. Older men reported they would not usually prepare meals, grocery shop, manage money, or use a telephone, although using a telephone was rated as being the most difficult activity to complete compared to women. These findings challenge the relevance of reviewing complex ADLs for older men as these may not be appropriate. These studies suggest further research is needed to understand whether men did not complete complex activities out of choice or because they were unable to.

There is also a gap in literature regarding older men’s engagement in completing ADLs as there are mixed explanations of why men continue to complete them despite being at risk of falling.

Older men report feeling a falls event may be inevitable and continue with their meaningful occupations, or report feeling demasculinised if being unable to complete activities they were once able to complete (Liddle et al., 2019). Older men had high outcomes of experiencing a fall event outdoors due to environmental hazards including uneven or broken footpaths, uneven walking surfaces, or rubbish (Lee, 2021). These findings remain consistent with Li et al. (2017), who found that older men were more likely to remain active outdoors, particularly when walking or running, attending club meetings, or when at home completing heavy gardening.

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Older men also attributed any falls experiences to external factors such as their environment or other people, so were less likely to consider it a fall but rather a trip or stumble (Stevens et al., 2018). Following a fall, men were less likely to seek falls prevention support or medical interventions, and when speaking to a healthcare professional about possible falls, only 24%

of men would openly discuss falls prevention (Stevens et al., 2012). Chang and Do (2015) discussed the prevalence of falls for women and men, finding that whilst women are more likely to fall or become injured from a fall, the morbidity rates from a fall are higher in men.

Contrastingly, however, Pereira et al. (2013) found that while women were more susceptible to experiencing a fall, if factors such as balance and comorbidities were equally assessed, men had a higher probability of falling. Despite this, men remain less likely to report a fall when experienced overall (Cuevas-Trisan, 2019).

2.3.3- Older men’s confidence in completing with falls risk and ADLs

Understanding men’s confidence in completing ADLs whilst at risk of falls is important as one study found that older men who experienced a fall or perceive themselves to be at risk of falls experience higher mobility difficulties, undertook less physical activity, and reported a lower quality of life (Jefferis et al., 2014). Additionally, older men often withdrew from the activity entirely if they felt a fall event would reoccur or activity modifications were not made, which led to a decline in their overall physical function (Jefferis et al., 2014).

When examining men’s confidence levels with a risk of falls, a fear of falling is most commonly researched due to the psychological impact that a fall has on independence and quality of life (Pohl et al., 2015b). Jefferis et al. (2014) examined the fear of falling for older men, with the study indicating that only half of the men who reported being fearful of falling had fallen in the previous year. Also, men who reported being fearful of falling also experienced lower confidence levels, lower exercise levels, higher sedentary behaviours, and higher levels of depression (Jefferis et al., 2014). This was supported by a study in New Zealand, which found both non-Māori and Māori men were more likely to fall if experiencing depression and were fearful of falling (Atlas et al., 2017).

While fear of falling has been well researched (Liu et al., 2021; MacKay et al., 2021), there are few studies of older men’s confidence levels when completing ADLs. Li et al. (2019) investigated older adult’s confidence in self-managing falls and its association with health and

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function. The study found that older adults who felt they had high physical functional levels thought they were less likely to fall, whilst older adults who felt they were at falls risk would stay home or avoid activities to reduce the risk of falling. This is contrasted by Jefferis et al.

(2015) and Kawasaki and Tozawa (2020) who explained that older adults who had over- estimated their physical function were just as likely to fall as older adults with less physical function. A gap in research is evident pertaining to older men and their confidence levels with ADLs and falls risk.

2.4- The role of occupational therapy with falls and ADLs

Describing occupational therapy input can be complex as it is delivered in many settings across healthcare. In a simplistic manner, Hagedorn (2000) explained that occupations can be comprised of four areas of ADLs that individuals complete regularly; play, work, leisure, and self-care. The foundational concepts of occupational therapy that are taught to students in New Zealand studying to become occupational therapists is the persons, occupation, and environment model (POE) (Auckland University of Technology, 2022; Otago Polytechnic, 2022). The POE is a well-established model that occupational therapists apply when working with individuals as it allows the therapist to support an individual holistically. The person is the client or patient that an occupational therapy aims to support, with the occupation being any area of ADLs previously mentioned; play, work, leisure, and self-care. The environment is viewed as both the physical space where occupations take place, but also how a person is able to perform occupations within that space (Baptiste, 2017). Occupational therapists work with individuals to ensure there is an occupational ‘fit’ in how individuals are able to perform occupations, and if there is any difficulties in doing so, this is addressed by the occupational therapy (Hagedorn, 2000).

Within ADLs and falls, occupational therapists provide support when there may be a ‘mist-fit’

between how older persons are able to perform in any ADLs without increasing the risk of falling. As falls are more likely to occur at home (Mulley, 2001), occupational therapists who work in the community may visit an individual’s home to provide housing modifications or equipment supports to assist older persons in reducing their falls risk (Ganz & Latham, 2020).

Housing modifications can involve changing the environment to create more efficient spaces such as widening the hallways to allow from walking frames, installing ramps to remove stairs for ease of access in and out of the home, and installing rails for holding on to when completing

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transfers such as in and out of showers (Wellecke et al., 2022). Smaller but also efficient changes in the home includes removing rugs or cords on the ground, opening up the space in rooms, and keeping items in easy to reach places to reduce falls hazards (Clemson et al., 2019).

Equipment is also a regular recommendation occupational therapists advise to support older persons with minimising falls in the home, such as toilet raisers, shower seats, and a reacher which acts as an extended arm for picking items up off of the ground (Clemson et al., 2019).

Housing modifications and equipment recommendations have been proven to reduce older persons risk of falls and is regularly used as falls prevention interventions to ensure older persons are able to remain safe when continuing to complete their ADLs (Maggi et al., 2018).

Physiotherapists and General Practitioners (GPs) largely support older persons with their falls, taking a biomechanical and medical approach through strength and balance interventions as well as medication prescriptions (Freiberger et al., 2013; Mackenzie & McIntyre, 2019;

Meekes et al., 2021b). When occupational therapists are involved in falls and ADL participation, this is predominantly to support older persons with equipment recommendations, and changes or modifications to the home environment to reduce the risk of falls in one’s home (Maggi et al., 2018). However, occupational therapy input is beneficial for supporting older persons as occupational therapists examine meaningful activities that may be restricted due to falls (Mackenzie & McIntyre, 2019). A multi-disciplinary approach where a functional lens from physiotherapists as well as an occupational therapy approach into the POE fit can be useful for receiving a holistic healthcare approach for older persons (Sherrington & Tiedemann, 2015; Tolley & Atwal, 2003). Understanding the implications of clinician-assessed, self- assessed falls risk, and confidence in completing ADLs without falling can aid in further developing meaningful and holistic approaches to falls education. Further research from an occupational therapy perspective in relation to falls risk and ADLs is required as there remains a gap in research around how older men are supported with their falls risk and confidence in completing ADLs.

2.5- Assessments of falls risk

Assessing falls risk is a key component to determining if an individual is likely to fall, or if they have fallen, to what degree are they at risk of falling again. Healthcare professionals can complete clinical assessments of falls and identify individuals who may be at falls risk, aiding in older persons reducing their falls risk by up to 24% (Phelan et al., 2015), although healthcare

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professionals may feel they did not have the skills or appropriate knowledge to assess older persons on their falls risk (Howland et al., 2018). Assessment tools for determining an individual’s falls risk are often standardised assessments that examine strength, balance, physical function, and gait (Meekes et al., 2021a). Common standardised falls assessments include the Timed Up and Go (TUG), chair stand test, four-stage balance test, Berg balance scale, and the Tinetti Performance Orientated Mobility Assessment (POMA) (Meekes et al., 2021a).

The TUG test is an easy to use, time efficient falls assessment tool that requires minimal equipment and no cost. Podsiadllo and Richardson published the TUG test in 1991 after expanding the tool ‘Get Up and Go’ due to the tools’ poor consistency measures. The TUG has been randomly assessed and the effectiveness of the tool (normative reference value) has been proven for persons aged 20 to 99 years old (Kear et al., 2017). The 30-second chair stand test is a good indicator to predict lower extremity muscle strength but is a discriminating test of individual’s physical activity level and endurance rather than a falls predictor and is not a useful standalone tool when measuring an individual’s falls risk (Lein et al., 2022). The four-stage balance test is a useful tool for examining static balance in a gradual progression across four stances (Mancini & Horak, 2010), although a single stance is often examined rather than the four stances for time-effectiveness. Franchigioni et al. (2010) found that the one-legged stance in the four-stage balance test was too difficult for persons with balance difficulties and was limited in the assessment of static balance control.

The Berg balance scale was developed in 1989 by Katherine Berg and co-authors to assess balance for older persons, although it is now used as a generic balance test for all individuals.

The Berg balance scale is a useful predictor of the level of falls risk though it is a time demanding and does not evaluate important changes to the balance of older persons (Downs et al., 2013; Downs et al., 2014). The Tinetti Performance Oriented Mobility Assessment (POMA) was developed by Mary Tinetti in 1986 and is regularly used to assess falls risk. It is a 28-item tool taking 15 minutes to complete, with several adaptations to the tool made since initial publication (Tinetti et al., 1990). Whilst the POMA has been evaluated as the most appropriate tool compared to the TUG and Berg balance scale due to its simplicity and effectiveness, (Korah, 2014), the test had lessened sensitivity, meaning it was not able to correctly identify individuals falls risk consistently enough to be used as a standalone falls assessment tool (Omaña et al., 2021).

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There is a large range of standardised assessments for determining falls risk in addition to those mentioned above. Gate et al. (2008) reviewed 29 assessment tools and determined that no single tool could adequately predict an individual’s risk of falls. However, the use of two or more falls assessment tools could provide a better evaluation of falls risk as multiple areas of an individual’s physical characteristics were being assessed (Park, 2018).

Despite the fact standardised assessments of falls are insightful tools for healthcare professionals to use, not all older persons seek medical support from a fall (Mulley, 2001).

Self-rated assessments of falls risk can be an important measure for individuals to determine if they feel at risk of falling when completing daily activities. More specifically, individuals can review their confidence in completing activities while at risk of falls (Soh et al., 2021). There are falls efficacy assessments and confidence assessments that can be used for older persons, including the Falls Efficacy Scale (FES), the modified Falls Efficacy Scale (mFES), and the Activity-specific Balance Confidence scale (ABC).

Mary Tinetti not only developed standardised falls assessments, but also developed the FES in 1990 to measure individual’s fear of falling when completing 10 basic ADLs (Tinetti et al., 1990). The FES has been proven to be relevant and easily understood, although does not provide a significant difference when identifying individuals at falls risk compared to those not at falls risk (Greenberg et al., 2021; Soh et al., 2021). Compared to the FES, the mFES was developed to enable responses in more common activities such as light gardening, crossing the road and using public transportation. These complex activities provide more understanding in challenging activities that are not included in the FES scale (Edwards & Lockett., 2008). The ABC scale is a 16-item questionnaire in which individuals rate their perceived confidence in completing 16 ADLs. It is a good predictor of individual’s confidence levels but highlights the activities that people avoid rather than activities they would typically complete (Mancini &

Horak, 2010).

Standardised assessments and self-rated assessments of falls risk are useful when two or more assessments are completed together as they enhance the accuracy of results for individuals when determining the level of falls risk. Nevertheless, it is important to know who conducts the assessments, or who can guide older persons, support workers, or family members in using self-rated assessments to assess an individual’s falls risk (Phelan et al., 2015).

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Te Tiriti o Waitangi, the Treaty of Waitangi, was signed in 1840 to protect Māori culture and the indigenous people whilst allowing colonisers to settle in NZ and establish government (Orange, 2021). According to Te Tiriti, three main principles of partnership, protection, and participation were highlighted in the articles that underpinned the alliance between the signing parties. These principles aimed to work collaboratively with upholding health and disability services in NZ, provide equitable efforts to achieve health outcomes for Māori, and enable equal opportunities to the Māori population (Orange, 2021). There is a large disparity in the experiences and outcomes of healthcare, founded on Westernised practice for New Zealand, particularly for Māori (Hamley & Le Grice, 2021; Palmer et al., 2019). At an operational level, bicultural practice in healthcare requires changes in healthcare provision and practice in order to tailor appropriate treatment to different cultures (Hikaka et al., 2021). Ensuring bicultural practice and upholding Te Tiriti principles is mandated in health professional competencies, such as the Occupational Therapy Board of New Zealand (OTBNZ). There are five competencies to ensure occupational therapy practitioners are practicing in a way that demonstrates the characteristics of the profession, as well as practicing in a bicultural manner to enhance the knowledge and protocols of Te Ao Māori (Māori worldview) (Silcock et al., 2017).Conducting this research to understand men’s assessed falls risk and self-assessed falls related to ADLs with inclusion of Māori participants upholds Te Tiriti principles and occupational therapy competencies, supporting more informative knowledge in the falls prevention paradigm with cultural inclusion, supporting work towards equitable health outcomes.

As previously discussed, the research on falls for men is lacking, with little information available in falls research for Māori men. The few studies that have analysed falls in a bicultural lens in New Zealand found that whilst Māori were less likely to fall than non-Māori, this was only up to a 10% difference in fall reports. However, Māori men were more likely to fall if experiencing depression, gait difficulties, and cognitive health-related issues (Atlas et al., 2017;

Hayman et al., 2012; Lord et al., 2020). Furthermore, 77% of Māori men and 76% of non- Māori men aged 80 to 90 years old reported needing support with completing ADLs, although Māori men were less likely to ask for or receive support with ADLs (Kerse, 2014a). With studies for Māori slowly emerging but yet still limited, no research pertaining to men’s falls risk and confidence in ADLs has yet been published. Ensuring Māori participants are included

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in research will support bicultural inclusivity and work towards achieving equitable outcomes in the education of falls research for both non-Māori and Māori men.

2.7- Falls, ADLs, and men’s confidence

While research has independently reviewed physical decline with age, activities of daily living, falls, and men, few studies have combined several of these factors to complete a more comprehensive examination of falls risk for older men and how men feel completing ADLs without falling.

Mamikonian-Zarpas and Lagana (2015) conducted a retrospective study reviewing difficulties in ADLs or a past fall experience being a predictor for future falls occurring in older adults.

The findings concluded 12 ADLs that older adults had difficulties with completing, in addition to risk factors such as frailty, that related to a risk of future falls in older adults. The study noted participants were aged 70 years and older, and of the participants sampled, only 34% were men.

Furthermore, participants answered the screening of ADL difficulty with a ‘yes/no’ response but did not have an opportunity to elaborate on to what extent the participants felt confident in completing the ADLs. In a study similar, Sekaran et al. (2013) hypothesized that falls were a predictor for difficulties in future ADL participation. They found participant’s previous two years of falls history was a predictor for difficulties in completing ADLs, with an increased risk of falls if the participants had not reported or received healthcare input following a fall. A limitation with the study was the discussion of participant’s gender. From 10 years of data collection, only the first year’s data was discussed in relation to gender, which showed 44% of participants were male. However, it remains unclear if this percentage is consistent throughout the following nine years of data collection.

The two previously mentioned studies (Mamikonian-Zarpas & Lagana, 2015; Sekaran et al., 2013) are based on research from 1984-1990 and 1998-2008 respectively, which may not reflect an accurate modern population sample. Conducting current research will provide a more accurate insight into the risk of falls and confidence in completing ADLs to support or update previous knowledge within these topics.

More recent studies have examined the psychological components of predicting falls, such as looking at fear avoidance behaviours, balance confidence, ability to self-manage falls, and self- awareness of falls risk. Landers et al. (2016) conducted a study on sixty-four participants who

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completed physical and psychological tests to determine what measure could better predict falls in older adults. They concluded tests of balance confidence and fear avoidance behaviours were the best predictors of determining a future fall, while the Timed Up and Go test was the best physical assessment of determining falls risk.

Similarly, Tsang et al. (2022) also studied self-perceived balance confidence and agreed balance confidence is a significant factor in predicting future falls. However, older adults who are aware of their falls risk may not take preventative measures to adequately reduce their falls risk. Pohl et al. (2015a) studied falls risk awareness and safety precautions taken by older adults and found that although older adults may be aware of their falls risk, they may adjust their perception of the impacts of falls risk to continue participating in activities. Specifically, older men felt demasculinized when not able to perform activities they used to be able to in earlier life stages.

These studies had a varying degree of equal gender inclusion, with Landers et al. (2016) including 38% men, Tsang et al. (2022) including only 19% men, and Pohl et al. (2015a) including 44% men. With a mixed percentage of males included in the studies and no discussions on how the balance confidence or psychological components impact ADLs, the results encourage further research and contribute to the growing evidence that future studies need to focus on the gender gap in literature.

2.8- Summary

Literature for older adult’s falls risk and ADLs has been well researched and presented above.

However, it remains difficult to find research for older men and how their assessed falls risk compares to their confidence in completing ADLs without falling. There is a growing demand for research pertaining to men, their risk of falls, and confidence in completing ADLs without falling. Additionally, future research for older persons needs to be generalisable to both gender groups. This evident gap in the literature for research to be completed, this has led to the development of the research question in this project

Research question: Is there a relationship between the clinician-assessed falls risk for older men compared to their self-assessed confidence in completing activities of daily living without falling?

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Chapter 3: Methodology

This chapter provides an outline and rationale for the methodology and methods used to answer the research question risking from the review of literature. A quantitative approach and retrospective cohort study lens is used in this research project. Methods of descriptive statistics will be explained, followed by the sampling method, and how rigour was maintained through use of reliability and validity. Data collection will explain how client files were obtained, who was included in the study, what the inclusion and exclusion criteria’s were, and an outline of Māori consultation and ethical approval. The data collection tools including clinician-assessed falls risk assessments and self-assessed falls risk assessment will be explained, before concluding with a discussion of the statistical analysis tools of how the data was analysed.

3.1- Research methodology and suitability

A quantitative epistemology approach is used to understand how knowledge is formed from information that currently exists, aiming to reveal an objective truth in the data available and measuring this as accurately as possible (Godwin et al., 2021). A quantitative methodological approach for this project is ideal to identify and understand the relationship of older men’s clinician-assessed falls risk and their self-rated assessment of confidence in ADLs without falling. The quantitative approach for this research supports the correlational exploration of data rather than a causational exploration which cannot be explored in a retrospective research as data has already been obtained. A correlational exploration can reveal if there is knowledge to be observed first before conducting further research or a causational exploration, while also being a pragmatic approach due to time constraints with conducting an experimental design (Ellis, 2014; Mohajan, 2020). Existing participant records included three standardised clinician-assessed falls risk assessments and one self-assessed numerical scores for falls risk while undertaking 14 ADLs.

A retrospective methodology used to answer the research question was beneficial to analyse data previously collected to determine the feasibility of the research question. Additionally, a retrospective lens is time efficient, cost-effective and can support clarity regarding a need for prospective studies (Sedgwick, 2014; Tofthagen, 2012). While a prospective methods study would have enabled the collection of data to identify a causality of the relationship identified, this study was completed without incurring a substantial investment of time and demand on the

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participants. A prospective study would have offered no additional advantages over the retrospective study as existing records provide the same information for data already collected as it would have for collecting future participant data (Sedgwick, 2014). Furthermore, permission was granted by the private health company to conduct a case review of existing records of participants who had completed their falls prevention programme over the last four years and was readily accessible. Retrospective studies are also referred to as chart reviews due to the data being sourced through medical records to aid in the understanding of current medical and psychological queries (Hess, 2004; Sedgwick, 2014). A chart review was desirable for this study as participants had completed clinician-assessed falls risk assessments and self-rated assessments of their confidence in completing ADLs without falling. The data was readily available for the research project, supporting time constraints of the project, and facilitated the exploration of data analysis to identify if there was knowledge to be found.

An additional benefit of using a retrospective methodology was the analysis of previously collected data at two periods in time, further enhancing the validity of the research. Participants who completed the falls prevention programme with the private health company were required to complete both clinician-assessed falls risk assessments and self-assessed falls risk assessments at the start of the programme and again on discharge. As participants were only included in the study if they had completed a falls prevention programme with the private health company, this ensured there were two datasets were available to be analysed.

Retrospective studies often use pre-existing medical records for comparing the effectiveness of interventions, but this study takes an innovative approach by collating assessments that are often analysed individually and identifying if there is a relationship. This research can inform possible prospective studies of future directions in exploring the relationship of falls risk for older men and their confidence in completing ADLs without falling if this is found (Shenvi et al., 2015). The two datasets analysed are referred to as ‘time period one’ (on assessment), and

‘time period two’ (on discharge) of the falls programme.

3.2- Methods

Descriptive statistics were utilised to discuss the data collated and produced in this research.

The use of descriptive statistics provides information of the variables examined, highlighting the relationships that may arise and enabling discussions of answering the research for future research insights (Talari & Goyal, 2020). The analysis from descriptive statistics was

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favourable as there were numerous relationships from the variables revealed in research which required a simplified analysis of the data that descriptive statistics provided (Yellapu, 2018).

3.3- Sampling

For this study, purposive sampling was used for collecting the participants within this study.

While purposive sampling may be construed as subjective sampling at times, this enables researchers to select a chosen subset of participants (Acharya et al., 2013). Purposive sampling is used as a non-probability sampling method to individually collate the samples to provide a more accurate reflection of the participant group required for research (Acharya et al., 2013).

Specifically for this study, the literature reviewed above highlighted a gap in older persons support in the falls space, being older men. The sampling perspective enabled older men to be the primary participant group sampled, with the specific age group of 65 to 74 years included.

The advantage of using purposive sampling was to provide generalisable results within the confines of falls prevention older men and support the discussions made once the results were analysed (Campbell et al., 2020). An alternative sampling method that could have been used is convenience sampling, where the most accessible participants could have been selected for the study, for example the first 50 men in the list of older men from client files. However, this could have led to sampling bias or selection bias which can be common in a cohort-based study (Etikan & Bala, 2017). Following careful consideration of possible sampling methods available, purposive sampling was chosen as the most suitable sampling method to be used in this research project due to the specific inclusion criteria and lens taken in the falls and ADL topics.

3.4- Rigour

3.4.1- Reliability

There are limitations of a retrospective cohort study with a chart review, such as missing data sets and recall bias. The data was collected from interventions previously completed, therefore data may have been missing in the intervention outcomes (Talari & Goyal, 2020). As information may be missed, researchers may revisit the participants to fill in the missing details, resulting in recall bias. Recall bias can impact the accuracy of the results due to the potential for information to be altered or changed (Kaji et al., 2014). Recall bias and missing data sets were addressed in this study by the development of an inclusion and exclusion criteria to ensure

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the data collected remained relevant, minimised biases, and meet the criteria for this research.

The inclusion criteria allowed for the partial completion of clinician-assessed or self-assessed falls risk assessments to be included in the study, preventing the need for revisiting participants for additional information.

Inter-rater reliability was maintained through the private health company’s annual in-service training which educated clinicians on how to conduct the falls assessments and facilitate the six month falls prevention programme. Additionally, the private health company ensures that when new clinicians start at the workplace, they observe and then complete the programme with another trained clinician before being cleared by internal trainers to complete the service independently. The use of annual in-service trainings and ongoing training for new clinicians enhances consistency in scoring participants for their falls risk and improves the reliability outcome for the research (Heale & Twycross, 2015).

3.4.2- Validity

Content validity ensured the study had adequate assessments to support appropriate outcome measures for participants and recommendations made following data analysis. The clinician- assessed falls risk assessments were mentioned earlier in this chapter for their relevant application to assessing falls risk, with research and validity references used to support each assessment. The three assessments were combined, and a four-point Likert scale was used to indicate participants level of falls risk. This ensured a larger scope of strength and balance aspects including static balance, endurance and mobility were measured for a comprehensive falls risk assessment (Phelan et al., 2015).

External validity was considered throughout the research to ensure the recommendations were as generalisable as possible. An impact of completing this study using a specific age group and gender signifies that generalisability is specific to the chosen population (Andrade, 2021;

Higgins & Straub, 2006; Patino & Ferreira, 2018). However, as the overall literature of falls risk is predominantly based on women (Schoene et al., 2019; Tricco et al., 2017), conducting this study for men contributes towards achieving equitable outcomes and further enhancing the literature for both genders in falls research.

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33 3.5- Data collection

3.5.1- Obtaining client files

Medical records, including the falls risk data, were collected from a private health company based in New Zealand. The company provided written support and approval for the data to be analysed in this research (see Appendix F). Data was collected from participants were based in the Auckland region, as this is where the company holds a contract for a falls prevention programme. The duration timeframe of the study was over four years from 2018 to 2022 which supported a larger number of client files being available for research, improving the generalisability of the data analysed (Simpson, 2015).

3.5.2- Participants criteria

The participants selected were older men between 65 to 74 years old. Age ranges for older adults are divided into three groups; youngest-old between 65 and 74 years old, middle-old between 75 and 84 years old, and oldest-old over 85 years old (Lee et al., 2018). While the divided age ranges provide a useful indication of age classification amongst the elderly population, recent data has highlighted that in New Zealand, the average life expectancy for non-Māori men is 80.9 years old, compared to 73.4 years old for Māori men (Stats NZ, 2021).

As healthcare professionals aim to provide bicultural care and considerations not only within practice but research also, portraying an appropriate age range for the culture of New Zealand is important for accurate representation (Parr-Brownlie et al., 2020). The ‘young-old’ age bracket enables older men who were both Māori and non-Māori to be better encapsulated in this study while first establishing if there is a relationship between the two variables of the research question, before expanding on the age range to include all older persons above 65 years old.

Awareness of the terms ‘male’ and ‘gender’ were considered as the researchers acknowledge these terms can be used fluidly and persons who may typically be seen as ‘male’ or stereotyped into a gender may feel otherwise. As this study is taking a retrospective approach, the data was already entered into the private health company’s database where the gender terms were assigned. Any participants who had left their gender section blank or as female were excluded from the study to reduce any bias from occurring. The term ‘gender’ or ‘gender-specific’ will

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take a view of participants who classified themselves as ‘male’, but the researchers are aware this term could be used more broadly in future studies.

3.5.3- Inclusion and exclusion criteria

Inclusion and exclusion criteria are specified to ensure expl

Older men’s falls risk and confidence in completing activities of daily living: A retrospective cohort study