Older Adults RecallOlder Adults Recall Key Fall Prevention Messages

after Social Marketing to Promote Balance Classesto Promote Balance Classes

through Churches

Carolyn DiGuiseppi, MD, PhDColorado School of Public HealthColorado School of Public Health

CollaboratorsCollaborators Colorado Department of Public Health and Environmentp

Sallie Thoreson, MS University of Utah

Lauren Clark, RN, PhD Worldways Social Marketing

Mark Marosits MS Mark Marosits, MS Colorado School of Public Health, University of Colorado

Denver & Colorado Injury Control Research Center j y Cynthia Goss, MA Dustin Currie

D i L tt PhD Dennis Lezotte, PhD

Few older adults take b l i lbalance exercise classes

Belief that falls in old age are inevitable

Fear of falling Discomfort with Discomfort with

group exercise classesclasses

Lack of available and accessible classesaccessible classes

Social MarketingSocial Marketing

Uses persuasion to motivate the voluntary Uses persuasion to motivate the voluntary behavior of target audiences

Offers products that target market Offers products that target market members perceive to be in their own best interestinterest

Shown to increase preventive health b h i i ld d ltbehaviors in older adults

Could be effective for persuading older adults to take balance classes

Study ObjectivesStudy Objectives

Examine awareness and recall of social Examine awareness and recall of social marketing messages about balance classes among older adults exposedclasses among older adults exposed through their churches

Two western Colorado counties (pop. 177,415)Two western Colorado counties (pop. 177,415)One city, few small towns, otherwise ruralOne city, few small towns, otherwise rural

Study Design: Cluster RandomizedCluster Randomized

Controlled Trial

Enrolled Churches

Intervention (Social Marketing)

Churches

ControlChurchesRand.

Churches

Older Adult Members

Older Adult Members

Social Marketing ProgramSocial Marketing Program

“Prevent future falls by attending the N’Balance class”

“Keep your independence with a better senseKeep your independence with a better sense of BALANCE”

-Authoritative endorsement-Pulpit announcements-Church bulletins

-Peer marketing-Trained ‘Church Messengers’

-Newsletter articles-Newsletter articles-Marketing messages-Schedules, locations

Social Marketing Programg gImplementation

Implemented by health department staff Each church received on average four Each church received on average four

month-long marketing ‘waves’Brochures posters pulpit announcements and Brochures, posters, pulpit announcements and informal conversations >90% of churches

Bulletins newsletters >75% of churches Bulletins, newsletters >75% of churches

OutcomesOutcomes

Awareness of messages Awareness of messages “Have you heard or seen any information about

balance classes falls or exercise to preventbalance classes, falls or exercise to prevent falls at your church or from its members?”

Recall of specific messages and Recall of specific messages and communication channels “What information about have you heard or What information about …. have you heard or

seen …?” “How did you hear or see information about ?” How did you hear or see information about ...?

Data CollectionData CollectionData CollectionData Collection

In each church mail survey of ~6% random In each church, mail survey of 6% random sample of older adult church members ~one year after enrollmentyear after enrollment Multiple mailings, $2 incentive

Mail survey included: Mail survey included: Awareness and recall of information

F f d h h Frequency of attendance at church Fall history, fear of falling Health status, demographics

Data analysisData analysisData analysisData analysis

Compared message awareness and recall Compared message awareness and recall between study groups using logistic regression modelsregression models

All models included random effect for church to account for intra clusterchurch to account for intra-cluster correlationM lti i t d l d t dj t f Multivariate models used to adjust for confounding

Results: RecruitmentResults: Recruitment

51 Enrolled Churches

26 Social Marketing 25 ControlR d26 Social MarketingProgram Churches

25 ControlChurchesRand.

3580 Older Adult Members

3521 Older Adult Members MembersMembers

Churches: Baseline CharacteristicsChurches: Baseline CharacteristicsSocial ControlSocial

MarketingControl

Mean total membership 484 620

Mean % of congregation aged 60+(range 5% - 90%)

45% 48%

Mean number of services per week 3.0 2.7

% Protestant 77% 88%% Protestant 77% 88%

% Rural Location 39% 40%

Church leader’s willingness to market* 3.4 3.4

Church leader’s perceived effectiveness of 3 2 3 1Church leader s perceived effectiveness of balance classes for fall prevention*

3.2 3.1

*(1=not at all, 5 = extremely)

Mail SurveyMail SurveyMail SurveyMail Survey

281 Congregants aged 60 and older 281 Congregants aged 60 and older Estimated response rate = 62%

64% Female, 96% White Age: mean 72.5 years Education: mean 14.8 years No sociodemographic differences No sociodemographic differences

between study groups

SocialMarketingChurch

ControlChurch 

Respondent Characteristics

Church Members (n=149)

Members (n=131)

Attends church at least weekly 70% 82%

Fell at least once in past year 46% 38%

High concern about falling 35% 38%

Very good or excellent health 56% 53%

S i fi d i fi d i h lif 94% 92%Satisfied or very satisfied with life 94% 92%

Awareness of MessagesAwareness of MessagesHave you heard or seen any information about Have you heard or seen any information about 

balance classes, falls or balance classes, falls or exercise to prevent falls…??

60%Social Marketing Control

40%

50%

20%

30%

40%

10%

20%

0%

At church / from members

Awareness of MessagesAwareness of MessagesHave you heard or seen any information about Have you heard or seen any information about 

balance classes, falls or balance classes, falls or exercise to prevent falls…??

60%Social Marketing Control

40%

50%

20%

30%

40%

0%

10%

20%

0%

At church / from members From other sources

Awareness of MessagesAwareness of MessagesAwareness of MessagesAwareness of MessagesHeard or seen any information about balance l f ll f ll ?classes, falls or exercise to prevent falls?

Adjusted Odds Ratio* (95% CI)(95% CI)

At church or from church b 7.7 (3.1, 18.7)members 7.7 (3.1, 18.7)

From any other sources 0.8 (0.5, 1.4)(e.g., TV, MD) 0.8 (0.5, 1.4)

*Adjusted for clustering by church, frequency of church attendance

Recall of MessagesRecall of MessagesWhat information … heard or seen about balance classes, falls or exercise to prevent falls at church or from church members?

35%Social Marketing Control

20%25%30%

10%15%20%

0%5%10%

Prevent falls w/ balance class

Balance classes available

Falls/ fall injuries serious

Recall of MessagesRecall of MessagesggWhat information have you heard or seen about balance classes falls or exercise to prevent falls at

Adjusted Odds Ratio*

balance classes, falls or exercise to prevent falls at church or from church members?

Adjusted Odds Ratio(95% CI)

P i f ll b ki b l l 6 2 (2 6 14 8)Preventing falls by taking a balance class 6.2 (2.6, 14.8)

Availability of balance classes in the  7 7 (2 6 22 9)community 7.7 (2.6, 22.9)

Seriousness of falls or fall injuries in ld d l 1.2 (0.4, 3.3)older adults 1.2 (0.4, 3.3)

*Adjusted for clustering by church, frequency of church attendance

Recall of Communication Channels:Recall of Communication Channels:“How did you hear or see information about ...?”How did you hear or see information about  ...?

(Intervention Church Members)

Church bulletin or newsletter

Conversation w/ church members

Pulpit announcement

B h

Poster

Presentation during services

Brochure

0% 10% 20% 30% 40% 50% 60% 70%

Limitations & StrengthsLimitations & StrengthsLimitations & StrengthsLimitations & Strengths

Survey response rate 62%Survey response rate 62% Survey response rate 62%Survey response rate 62% Generalizability of results to minorities, other Generalizability of results to minorities, other faithfaith based congregations highly urbanizedbased congregations highly urbanizedfaithfaith‐‐based congregations, highly urbanized based congregations, highly urbanized areasareas

Randomized controlled designRandomized controlled design Characteristics of respondents similar between Characteristics of respondents similar between groupsgroupsg pg p

Conclusions & ImplicationsConclusions & Implicationspp

Church based social marketing programs can effectively Church‐based social marketing programs can effectively reach older adults with messages about preventing falls through balance classesg

Such programs should take advantage of trusted communication channels such as church newsletters, bulletins, pulpit announcements Messages via other modalities (e.g., posters, brochures 

li d b ) l ff isupplied by program) appear less effective Further research should examine whether findings can be generalized to other populations and settingsgeneralized to other populations and settings

AcknowledgmentsAcknowledgments

The churches, their leaders and congregants whoThe churches, their leaders and congregants whoThe churches, their leaders and congregants who The churches, their leaders and congregants who participated in this studyparticipated in this study

Research assistants: Sarah Morehouse, Vedavani Research assistants: Sarah Morehouse, Vedavani ,,TiruveedhulaTiruveedhula

This project This project was supported was supported by Colorado Injury Control by Colorado Injury Control Research Center Research Center Grant Number R49/CCR811509 from Grant Number R49/CCR811509 from the Centers for Disease Control and Prevention.the Centers for Disease Control and Prevention. Its Its 

l l h ibili f h h dl l h ibili f h h dcontents are solely the responsibility of the authors and contents are solely the responsibility of the authors and do not necessarily represent do not necessarily represent official official views of the CDCviews of the CDC..

Questions?Questions?Questions?Questions?

Awareness and R llRecall

93% f b l l ti i t f 93% of balance class participants from intervention churches reported that they heard about the class through theirheard about the class through their church.

What kind of information did h t h h?you hear or see at church?

Availability of balance

B l l t f ll

Availability of balance classes

Falls and fall injuries are

Balance classes prevent falls

Other ways to prevent falls

jserious

Other message

Other ways to prevent falls

0% 20% 40% 60% 80%

Other message

How did you receive this How did you receive this information at your church?information at your church?information at your church?information at your church?

Church bulletin / newsletter

Conversation with church member

Pulpit announcement

Brochure

Conversation with church member

Presentations at services or events

Poster

Oth

Letter or email

0% 10% 20% 30% 40% 50% 60%

Other ways

Previous findings f thi t dfrom this study

Demonstrated that a social marketingDemonstrated that a social marketing program, implemented in churches, increased participation in balance classes p pby older adult church members

Number of Older Adults Enrolled in Number of Older Adults Enrolled in N’BalanceN’Balance Classes (total n=269)Classes (total n=269)

200

160180200

100120140

406080

02040

Intervention Control Churches Non Study or NoIntervention Churches

Control Churches Non-Study or No Church

Mean Proportion of Older Adult Congregants Mean Proportion of Older Adult Congregants Who Enrolled in Balance ClassWho Enrolled in Balance ClassWho Enrolled in Balance ClassWho Enrolled in Balance Class

12.0%

10.0%

6.0%

8.0% Z=-4.47, p<.001

4.0%

6.0%

2.0%

0.0%Intervention Churches Control Churches

Product: N’BalanceProduct: N Balance

Individualized Individualized balance, strength, sensory, gaitsensory, gait training

10 students/class Meets biweekly for

8 weeks (16 class (sessions)

158 Churches Assessed for

Results:R it t EligibilityRecruitment

29% Not Eligible (size, location)71% Eligible

51 Enrolled(46%)

61 Refused / Did Not Respond (54%)

26 Social Marketing Ch h ( 1%)

25 Control Ch h (49%) Churches (51%)

3521 OA MembersChurches (49%)

3580 OA Members