Chapter 1: INTRODUCTION
The purpose of this chapter is to present background information regarding the research area of
this study and to outline the rationale for selecting this research area. The chapter introduces the
research topics covered and outlines the purpose of this study before summarizing the content of
each chapter.
1.1. Introduction to Research Topic
Falls are a major cause of injury in older adults in the UK and injuries from falls impose
substantial financial burdens on the health services in the UK (Scuffham et al., 2003). Falls affect
many different factors of physical and mental well-being in older adults and this is reflected in
the variety of research areas concerning falls. Studies have been conducted to investigate
physiological factors linked to falls risk, such as, lower limb muscle strength, impaired vision,
reaction time, balance, peripheral sensation (Lord et al., 1994) and gait pattern (Maki, 1997).
Other areas of research have looked into the effects of falling, including the influence of falls on
psychological parameters such as fear of falling (Maki et al., 1991; Maki, 1997), falls efficacy
(Yardley et al., 2005) and quality of life (Cumming et al., 2000).
There are many known intrinsic and extrinsic risk factors for falling, including age, gender,
falls history, environmental hazards, footwear and clothing (WHO Europe, 2007) and it is difficult
to control for all these factors without deviating from common ethical principles. In any case,
without controlling these risk factors it is difficult to establish cause and effect relationships
between the risk factors and falling - an issue discussed in the literature review. However, the
identification of associated risk factors may be useful in the development of efficient and cost
effective methodologies for screening and reducing falls risk in older adults. As the ageing
population of the UK grows the development of cost effective preventative strategies to
minimise the number of patients admitted to hospital for falls-related injuries is vital (Scuffham
et al., 2003).
1.2. A Background to Falling
1.2.1.Population and life expectancies for older adults worldwide
Recent estimations indicate that in developed countries there are more older adults aged
over 60 years than children aged under 14 years and it is projected that by 2050 there will be a
ratio of two older adults for one every child (United Nations [UN], 2004). The 2004 revision of
the UN report of World Population Prospects estimated there to be 688 million older adults
1
aged over 65 years worldwide in 2005 based on the national census data collected in 2000 (UN,
2004) and that by the year 2050 this number would grow to be almost 2 billion. The same report
also projected that in more developed regions of the world there would be an increase in life
expectancy at birth from 76 years in 2005 to 82 years by 2050, with the percentage of the
population aged 60 years or over increasing from 20 per cent to 32 per cent by 2050.
1.2.2.Population and life expectancies for older adults in the UK and Wales
In Wales it is estimated that 10% of the population is comprised of adults aged between 65
and 74 years, and a further 9% of the population are over the age of 75 (Welsh Assembly
Government [WAG], 2010). With life expectancy for older adults increasing across the UK and in
Wales, the percentage of adults over the age of 60 years is also increasing. In Wales between
1931 and 2010 it is estimated that the number of adults aged between 65-74 years has
increased by 5%, while the number of adults aged over 75 years has increased by 7% (WAG,
2010). The most notable growth between the genders has been in the female population, which
has seen an increase from only 2% in 1931 to 10% of females over the age of 75 years in 2010
(WAG, 2010). The life expectancy of those born in Wales is 77.2 years for males and 81.6 years
for females (Office for National Statistics [ONS], 2011). Compared with this national average, life
expectancies at birth for those belonging to the same demographic group living in Ceredigion,
Mid-Wales are longer – 80.4 years and 84.1 years for males and females, respectively (ONS,
2011). Life expectancies identified less than ten years earlier in the same county were shorter
for men at 78.4 years and for women at 81.9 years which supports a predicted increase in life
expectancy within the county (ONS, 2007).
1.2.3.Falls incidence and injury
As risk of falling increases with age (Lord, 1990), so does risk of injury from accidental falls
(Scuffham et al., 2003). Combined with an ageing population this could be interpreted to
indicate that incidence of age-related illnesses and injuries from falls will continue to increase
(WHO, 2007), particularly if preventative measures are not taken in the immediate future.
Patients aged over 75 years are three times more likely to attend Accident and Emergency
services (A&E) as a result of an unintentional fall than any other age group, and are eleven times
more likely to be hospitalised after an unintentional fall than those in the 60-64 year age group
(Scuffham et al., 2003). Between 2007 and 2009, death rates from accidental falls in England and
Wales in adults aged 65-74 years were 8.7 per 100,000 (National Centre for Health Outcomes
Development [NCHOD], 2011). Moreover, rate of mortality in recurrent fallers has been
2
estimated to be around twice that of the general population (Gribbin et al., 2009).
Over 90% of hip fractures are associated with falls (Youm et al., 1999), and hip fracture
accounts for approximately two thirds of the cost of inpatient fracture care in the UK (Kanis,
1993). Hip, spine, upper arm and pelvic fractures have been found to be more common in older
adults – in particular in older women (Johansen et al., 1997) which is in agreement with findings
that indicate that older women are also more likely to experience a fall than their male
counterparts (Prudham and Evans, 1981).
Injuries caused by falls are a major cause of disability in people aged above 75 in the UK, and
therefore represent a major health concern for this growing age group (Scuffham et al., 2003).
When compared to the rest of the UK, the population of Wales has a lower disability-free life
expectancy than that of England; from the age of 65 years onwards men and women in Wales
are predicted to live with a disability for at least half of their remaining life (Breakwell and
Bajekal, 2006). In the case of hip fracture, increasing numbers of adults are living to an age
where they are at an increased risk of fracture (Marks, 2010). One of the factors contributing to
the growing ageing population of survivors from hip fracture is improved acute care, which will
result in increased health costs incurred by long-term health services provision for those who
encounter disability as a result of their fall (Marks, 2010). The increasing need for these services
in older adults has been attributed to an age-related tendency to experience illness as well as
increased time taken to recover from injury (Marks, 2010).
In 1997, overall fracture incidence in the UK was estimated to be 21.1/1000/year
(23.5/1000/year in males and 18.8/1000/year in females; Johansen et al., 1997). These estimates
were calculated using fracture incidence of patients admitted to the A & E Department at Cardiff
Royal Infirmary in the 12 months following April 1 1994. When applied to population estimates
of 51.6 million in England and Wales from the national census in 1994, overall fracture incidence
is estimated to have been 1.1 million that year (Johansen et al., 1997).
1.2.4.Cost of falling
Costs incurred by fall-related injury present a great economic burden on health services. In
1999 the total cost to the UK government of unintentional falls in older adults was estimated to
be £981 million – 59.2% of which was incurred by the NHS (Scuffham et al., 2003). In the same
year 78% of hospital admissions for fall related incidents were for patients aged over 75 years –
fall-related injuries in this age group alone incurred 66% of total costs (Scuffham et al., 2003).
Long-term care for falls accounted for 48.5% of total age group costs in adults over the age of 75
years for falls (Scuffham et al., 2003). Ten years on, present costs incurred by the NHS due to
3
falls are £1.7 billion per year (Age UK, 2010) – a marked increase of around £700 million since
1999. Therefore the cost of meeting the increasing requirements for provision of adequate
preventative measures and treatments for falls for the ageing UK population is growing
(Scuffham et al., 2003). Avoidance of long-term care costs may be possible if effective and cost
efficient falls prevention measures are implemented before patients develop multiple risk
factors for falling.
1.3. Study Outline
Multi-Factorial Falls Risk Assessments (MFFRA) and Interventions (MFFRI) are methods used
to identify and reduce falls risk in older adults (Tinetti et al., 1994). MFFRA may include a general
health examination, review of falls history and medications, home hazard and vision
assessments, as well as anthropometric measures and measures of strength and balance (Tinetti
et al., 1994). Corresponding MFFRI would aim to address risk factors identified in the MMFRA,
for example, they may involve changes to prescribed medication, home visits to assess hazards
in the patient’s home and alterations to optical prescriptions as well as offering patients the
opportunity to participate in exercise targeting strength and balance (Tinetti et al., 1994;
Davison et al., 2005).
One type of intervention targeted at reducing falls risk factors that has been examined is
exercise to improve strength and balance (Lord et al., 1994; Shumway-Cook et al., 1997; Yoo et
al., 2010). Physiological benefits of participation in exercise programmes in older adults have
been demonstrated, including improved balance, walking ability and strength (Shumway-Cook et
al., 1997). Research studies have also demonstrated that exercise interventions can result in
patients reporting improvements in psychological falls risk factors, for example, fear of falling
(Yoo et al., 2010).
However, psychological factors such as exercise motivation and influences on motivation, for
example psychological need satisfaction, have yet to be studied in participants of falls
prevention exercise interventions despite being applied to other sport and exercise research
settings (Bartholomew et al., 2011; Hagger et al., 2006). In fact, supervised post-treatment
exercise intervention prescribed to breast cancer survivors has been shown to encourage an
adaptive exercise motivational profile (Milne et al., 2008) – the effects of which could include
increased long term adherence to exercise. Results such as these could suggest that similar
results for change in motivation may be found in other patient groups participating in exercisebased interventions, including falls prevention programmes.
There is an also absence of research literature examining changes in psychological well-being
4
indicators throughout the course of participation in falls prevention interventions. Psychological
well-being indicators, such as quality of life, are often included in screening processes to identify
persons eligible for participation in studies, for example quality of life - however, these are not
often repeated after completion of the intervention (Lord et al., 2005). Therefore opportunities
to evaluate the effectiveness of falls prevention interventions in enhancing psychological wellbeing have been missed.
The purpose of this study is to examine changes in a range of psychological parameters in
participants of an exercise intervention targeting older adults with strength and balance deficits
and a history of falling. Some of these measures have been examined in the context of other falls
prevention interventions for older adults, including falls efficacy and fear of falling, while others
such as psychological need satisfaction, motivation and changes in self-reported quality of life
are unexplored in the context of falls interventions. Implications for findings could include
identification of modifiable psychological risk factors and benefits that could be used for
discrimination and evaluation of individuals.
1.4. An Overview of the Thesis
Chapter 2 presents a review of literature focusing on topics relevant to this study, including
critical discussion of findings from other studies that have contributed towards the hypotheses
forwarded in this study. Descriptions of the study design and methodology used to collect data
in the study are presented in Chapter 3, alongside the rationale for their use. Chapter 4 presents
the results, which include changes in participants’ psychological outcome measures over the
duration of the exercise intervention programme. These results are then discussed in Chapter 5
with reference to the literature discussed in Chapter 2. The final chapter, Chapter 6, draws fial
conclusions regarding the implications of the findings for understanding factors related to falls
risk in older adults, as well as the limitations of the study and future research questions that
require consideration.
1.5. Chapter Summary
This chapter has introduced the research area, outlined the focus for this study and provided
an overview of the contents of the thesis. The next chapter presents a review of literature
relevant to the topics of this study.
5
Chapter 2: LITERATURE REVIEW
The purpose of this chapter is to review literature concerning the research into falls and the
relationships demonstrated between psychological factors and risk of falling in older adults. The
beginning of the chapter concentrates on the definition and epidemiology of falling in the UK and
Wales, including incidence and health costs incurred by falling. The chapter then considers
interventions used to prevent falls. This is followed by a discussion of psychological theories and
outcome measures that have been used in previous falls research studies.
2.1. Definition of Falling
A faller is defined as someone who has fallen one or more times during the last six to twelve
months; a person who has fallen more than twice during this defined time period is considered a
recurrent faller (Masud and Morris, 2001). There are many variations in definitions of the term
falling used in research studies, including many subdivisions of the category of falls.
Many definitions commonly describe the event of falling as “unintentional” (Buchner et al.,
1993), “inadvertent” (Kellogg Group, 1987; Carter et al., 2002; Tideiksaar, 2002), “unexpected” (Lach
et al., 1991) or “involuntarily” (Means et al., 1996) – with the odd exception of “intentional”
(Tideiksaar, 2002). The Cochrane Review (Gillespie et al., 2009) identified that the most commonly
used definition for falling in studies was that of Buchner and colleagues (1993, p. 300):
“Unintentionally coming to rest on ground, floor, or other lower level; excludes coming to rest
against furniture, wall, or other structure.” The term “unintentional” refers to the absence of a
conscious or intentional action on the part of the faller that would result in them coming to rest on
the ground. There is often the addition of other specific inclusion and exclusion criteria to meet the
requirements of the study being conducted, for example, without loss of consciousness (Kellogg
Group, 1987) or “inadvertently coming to rest on the ground or other lower level with or without
loss of consciousness and other than as a consequence of sudden onset of paralysis, epileptic
seizure, excess alcohol intake, or overwhelming external force” (Close et al., 1999 p. 93). Different
definitions may specifically include (Tideiksaar, 2002) or exclude coming to rest on an item of
furniture (Buchner et al., 1993).
Falls can also be classified in different ways, for example: intentional or unintentional, (Scuffham
et al., 2003) and injurious or non-injurious (Koski et al., 1996). There are also differences in
interpretation of the meaning of the term ‘falling’ between groups, for example: health
professionals, researchers and high risk falls groups such as older adults (Zecevic et al., 2006).
Evidence has been found that when defining a fall older adults are more likely to focus on why, when
6
and how a fall happened as well as its consequences, for example, motor control (slip, trip or
stumble), loss of balance, environmental landing and injury, as opposed to describing the
biomechanical events of the fall itself – which is more commonly identified in research-based
definitions of falling (Zecevic et al., 2006). Falls are also more likely to be reported as “unspecified
falls” in older patients (Scuffham et al., 2003). It could be speculated that this is partly due to
differences in interpretation of the term falling between older adults, health professionals and
researchers.
The overall effect of the use of such a range of definitions can be the variation in the outcomes
for different studies (Masud and Morris, 2001), as well as outcomes for treatments and
interventions within health services (Zecevic et al., 2006). In 2005 the Prevention of Falls Network
Europe (ProFaNE) made recommendations for the development of a common outcome data set for
use in falls research which included definitions of terminology and research domains. Therefore the
definition used in this study is that recommended by ProFaNE, defining a fall as “an unexpected
event in which the participants come to rest on the ground, floor, or lower level” (Lamb et al., 2005,
p. 1619).
2.2. Risk Factors: Assessment and Intervention
2.2.1. Risk Factors for Falls
Risk of falling has been shown to increase with age (Lord, 1990; Prudham and Evans,
1981). Many risk factors for falling in older adults have been identified in the research
literature. A prospective community-based research study by Koski and colleagues (1996
found that injurious falls in older adults over the age of 70 are associated with older age,
absence of Achilles and quadriceps reflexes, muscular weakness, gait impairment, reduced
mid-arm circumference, impaired orthostatic reaction, reduced step length, use of four or
more medications, the use of long-acting benzodiazepines, calcium blockers, antiinflammatory drugs and antidiabetic drugs. In a systematic review of studies (Oliver et al.,
2004) looking at both individual clinical risk factors and clinical assessment tools for falls risk
in older adults, gait instability, agitated confusion, urinary incontinence, a history of falling
and prescription of sedative or hypnotics drugs were all repeatedly identified as significant
risk factors for falling in studies conducted across a range of research settings, populations
and risk factors. A report by WHO Europe (2007) presents a list of fourteen intrinsic and
three extrinsic risk factors associated with falling in older adults (See Table 2.1.).
Intrinsic Risk Factors
History of falling Impaired mobility and gait
Extrinsic Risk Factors
Environmental hazards
7
Age
Gender
Living alone
Ethnicity
Medicines
Medical conditions
Sedentary behaviour
Psychosocial status
Nutritional deficiencies
Impaired cognition
Visual impairments
Foot problems
Footwear and clothing
Inappropriate walking aids or
assistive devices
Table 2.1: Intrinsic and extrinsic risk factors selected from the research literature by WHO Europe (2007)
Differences in risk factors that may discriminate between fallers and recurrent fallers have
been suggested, for example visual contrast sensitivity, quadriceps strength, lower limb
proprioception, reaction time, and sway on a compliant (foam rubber) surface with the eyes
open (Lord et al., 2003). Findings from preliminary research studies like these have been
implemented in the development of clinical falls screening tools, such as the Physiological Profile
Assessment (PPA; Lord et al., 2003). Notably, however, all risk factors measured in this specific
screening tool are physiological and none are psychological – highlighting the need for increased
focus on such factors. Fear of falling is an example of a psychological risk factor for falls (Tinetti
et al., 1990), and has been shown to be greater in individuals with a history of falling (Arfken et
al., 1994). Fear of falling is discussed in a later section of this literature review.
Physiological risk factors have been shown to vary according to various intrinsic and extrinsic
parameters. As an example of this, differences in risk factors exist between intrinsic parameters
such as gender, for example, in men and women over the age of 70 years (Campbell et al., 1989;
Prudham and Evans, 1981). In men, increased body sway, decreased physical activity levels, gait
impairment, and a history of stroke and arthritis in the knees have been associated with an
increased risk of falls (Campbell et al., 1989). In contrast, systolic blood pressure lower than 110
mmHg while standing, total number of drugs, including psychotropic drugs and drugs liable to
cause postural hypotension, as well as evidence of muscle weakness are all factors that have
been associated with increased falls risk in women (Campbell et al., 1989; Koski et al., 1996).
It is possible for intrinsic risk factors to influence extrinsic risk factors. For example, intrinsic
risk factors such as frailty and poor hand grip strength have been associated with an increased
likelihood of being housebound – an extrinsic or environmental risk factor and as such those
who are more frail and weak are at greater risk of falling indoors (Bath and Morgan, 1999). In
contrast, more active individuals who spend greater amounts of time outdoors, for example
8
spending time walking for relaxation purposes, are more likely to experience a fall outdoors.
However, again this tendency for outdoor falls is also suggested to be a function of
compromised physical health status (Bath and Morgan, 1999).
Extrinsic risk factors such as footwear and environmental hazards (See Table 2.1) are
relatively simple to alter which makes them easy to control for in research studies and suitable
for inclusion in interventions to reduce risk and therefore they may be more likely to be
considered modifiable risk factors. However, intrinsic risk factors vary in their capacity for
modification. For example, intrinsic risk factors such as age, falls history, gender and ethnicity
are all un-modifiable risk factors for falls, however, other intrinsic risk factors, such as
medications, sedentary behaviour and visual problems are more easily modifiable. In particular
physical activity may be increased by increasing self-determined motivation and greater
psychological need satisfaction through application of psychological theories, such as Selfdetermination Theory (Ryan and Deci, 2000a) to provide environments which support these
changes, which is discussed later in this chapter.
The large number of studies looking at different risk factors and using different interventions
means that it is difficult to evaluate their effectiveness in reducing falls risk (Gillepsie et al.,
2009). This is also underpinned by unidentifiable risk factors that cannot be accounted for in
research studies, as well as risk factors that cannot be controlled by the researcher, such as
illnesses that have not yet been diagnosed. For example, participants of a study may have
undiagnosed early onset diseases such as Parkinson’s or Alzheimer’s diseases that are unlikely to
be reported in the screening process, but may influence measures of physiological or
psychological variables and thus influence the overall findings. Other lifestyle factors, such as
diet and access to transport and health services due to location can also be difficult to control
for in research studies. Due to these limitations it has not been possible to create a finite list of
all risk factors for falls, but to compile a relatively comprehensive group of risk factors – some of
which can be modified and controlled. The varying influence and interaction between risk
factors for different people and in different environments mean that falls risk assessments and
interventions must be individualised to meet in order to be most effective; however, some
standardisation in research studies is also needed to ensure findings are comparable.
2.2.2. Multi-Factorial Falls Risk Assessment
Multi-Factorial Falls Risk Assessments (MFFRA) are used to identify people at greater risk of
falling through the identification of the number and magnitude of risk factors affecting them.
Modifiable risk factors can then be addressed as part of a single or multi-factorial intervention.
9
Modifiable risk factors that have been measured as part of multi-factorial assessment in
research studies include both extrinsic and intrinsic risk factors, such as postural hypotension
(Tinetti et al., 1994), deficits of strength, balance and gait (Lord et al., 2003; Tinetti et al., 1994;
Shumway-Cook et al., 1997), impaired vision (Lord et al., 2003; Shumway-Cook et al., 1997) and
psychological parameters, such as falls efficacy or fear of falling (Tinetti et al., 1994; ShumwayCook et al., 1997), depression and level of independence in Activities of Daily Living (ADLs;
Tinetti et al., 1994). A risk assessment may also include an assessment of home hazards (Tinetti
et al., 1994), as well as a medications review (Tinetti et al., 1994).
2.2.3. Research-based evidence: Falls prevention interventions
Falls prevention interventions are used to modify risk factors identified in high risk
individuals during a falls risk assessment – with the purpose of reducing overall falls risk. In a
Cochrane review of 111 randomised controlled trials (RCT) comparing the effectiveness of
different interventions for falls (Gillespie et al., 2009) it was concluded that Multi-Factorial Falls
Risk Interventions (MFFRI) can help to reduce falls rates in community-dwelling older adults. It
was concluded that due to the complexity of MFFRI the precise factors that determine their
resulting effectiveness still need to be identified; the intervention methods used and the risk
factors which they target are varied, and so is their effectiveness for reducing falls risk and
incidence in older adults (See Table 2.2).
Table 2.2.: Falls interventions reviewed in the Cochrane review by Gillespie et al. (2009)
10
Other than in individuals with a vitamin D deficiency, the use of vitamin D supplements was
not found to reduce falls and with the exception of those with the highest baseline risk of falling,
such as those with visual impairment, home safety improvement also showed no beneficial
effect (Gillespie et al., 2009). Medication review was found to be effective in reducing falls risk,
particularly where reductions in medications to improve sleep, anxiety and depression were
identified (Gillespie et al., 2009). First eye cataract surgery and insertion of a pacemaker where
carotid sinus hypersensitivity was indicated were also found to be effective in reducing falls
incidence (Gillespie et al., 2009). Of all intervention methods reviewed, supervised group
exercise, including Tai Chi, as well as individually prescribed exercise programmes at home, are
suggested to be the most effective methods of reducing falls risk and incidence in older adults,
particularly if these programmes focus on improving two or more of the following: strength,
balance, flexibility, or endurance (Gillespie et al., 2009) as these interventions target the
reduction of known risk factors for falling, such as impaired mobility and sedentary behaviour
(See Table 2.1). The argument for use of exercise for the purpose of falls risk reduction is
supported by the conclusion of another systematic review of RCTs – which reports that
interventions including weight bearing, balance and strengthening exercise can be used to
reduce falls and fall-related fractures in individuals with low bone density (de Kam et al., 2009).
The results from this review showed that exercise-based interventions for targeting balance and
strength were effective in the majority of the studies for improving balance and strengthening
lower extremity muscles and back extensors respectively. Therefore a similar conclusion to that
of the Cochrane review (Gillespie et al., 2009) was made supporting the use of exercise to
reduce falls, fall-related fractures, and falls risk factors in this review. These include
recommendations for exercise interventions for patients with osteoporosis to use weightbearing activities, balance exercise, and strengthening exercises to reduce falls risk.
2.2.4. National Institute for Health and Clinical Excellence guidelines
In 2004 the National Institute for Clinical Excellence (NICE) released clinical practice
guidelines for the assessment and prevention of falls in older people in the UK called NICE
Clinical guideline 21 (NICE 21, 2004). The key priorities for implementation of these
guidelines include case/risk identification of falls in older adults, along with multi-factorial
falls risk assessment and interventions which health professionals must offer to patients
identified as being at risk of falling.
11
2.2.4.1.
Recommendations for Assessment of Falls Risk
NICE 21 (2004) recommends that those patients identified at risk of falling by healthcare
professionals should be assessed using an individualised multi-factorial falls risk
assessment. Components that may be included in the assessment are listed in the
guideline (see Figure 2.1 below).
An individualised multi-factorial assessment or intervention, as described in Figure
2.1, refers to assessment and intervention of patients’ individual risk factors. For
example, a patient requiring a MFFRA who has previously been diagnosed and
prescribed appropriate medication for osteoporosis would not be assessed for
osteoporosis. However, they may benefit from a medications review as part of their
assessment to identify if any of their other prescribed medications are “culprit” drugs,
and therefore a possible contributory risk factor to their recurrent falls.
Older people who present for medical attention because of a fall, or report recurrent falls in the past
year, or demonstrate abnormalities of gait and/or balance should be offered a multi-factorial falls risk
assessment. This assessment should be performed by healthcare professionals with appropriate skills
and experience, normally in the setting of a specialist falls service. This assessment should be part of
an individualised, multi-factorial intervention.
Multi-factorial assessment may include the following:
- identification of falls history
- assessment of gait, balance and mobility, and muscle weakness
- assessment of osteoporosis risk
- assessment of the older person’s perceived functional ability and fear relating to falling
- assessment of visual impairment
- assessment of cognitive impairment and neurological examination
- assessment of urinary incontinence
- assessment of home hazards
Figure 2.1: Recommendations for multi-factorial assessment in NICE Clinical Guideline 21 (2004; adapted from
p. 8-9).
12
2.2.4.2.
Recommendations for Preventative Interventions
The NICE guideline (2004) states that all older adults with a history of falling must be
considered for a multi-factorial intervention (see Figure 2.2 below).
All older people with recurrent falls or assessed as being at increased risk of falling should be
considered for an individualised multi-factorial intervention.
In successful multi-factorial intervention programmes the following specific components are common
(against a background of the general diagnosis and management of causes and recognised risk
factors):
- strength and balance training
- home hazard assessment and intervention
- vision assessment and referral
- medication review with modification/withdrawal.
Following treatment for an injurious fall, older people should be offered a multidisciplinary
assessment to identify and address future risk, and individualised intervention aimed at promoting
independence and improving physical and psychological function.
Figure 2.2.: Recommendations for multi-factorial interventions in NICE Clinical Guideline 21
(2004; adapted from p. 7)
While the recommendation is made for strength and balance training to be included
in multi-factorial interventions in NICE 21 guideline (2004) no specific recommendations
are made concerning how the interventions should be delivered and which exercises
should be included. More specific evidence-based recommendations (Skelton and Dinan,
1999) for components and delivery have been made for targeted exercise interventions
for reducing falls risk in the Guidelines for exercise programming for the frail elderly
(2005; See Appendix 2.1). For example, for large muscle groups resistance exercise
should include 8-10 repetitions building from 2 to 3 sets starting at 50% of each
individual’s one maximal repetition (1-RM) increasing to 80% over a period of 12 weeks.
Other recommendations concern the physical and social environment in which the
services are provided, including the abilities of the course instructor to communicate
and provide a socially supportive atmosphere in which participants are able to develop a
sense of ownership, and importantly pay attention to participants’ perceptions and
psychosocial need (See Appendix 2.1.), which include providing an enjoyable and social
atmosphere that contributes towards a nurturing environment for enhancing motivation
13
(Deci and Ryan, 2000a). The omission of these or similar evidence-based
recommendations in the NICE 21 guideline (2004) could be criticised as these are they
are critical in the development of standards for exercise based falls prevention
interventions.
2.2.4.3.
Recommendations for Research
In the 2004 NICE 21 guideline, recommendations were also made for future areas of
research concerning the development of effective and appropriate falls risk assessment
and intervention – these include the need to:

identify the components of multi-factorial interventions that are most important with
respect for reducing falls risk and cost-effective in different settings and patient groups

measure the impact of these interventions on reducing falls incidence and injury

investigate whether individuals can be stratified by falls risk to identify who will most
benefit from multi-factorial assessment and intervention.
2.2.4.4.
Review of Guidelines 2011
The 2011 review of NICE 21 guideline (NICE, 2011) was conducted by a Guideline
Development Group and a panel of stakeholders, which included members of the
National Patient Safety Agency, Vifor Pharma UK, Department of Health (England), Older
People and Dementia Branch, National Care Forum, British Psychological Society,
UKCPA, RCP, NHS direct, Royal National Institute of Blind People, British Dietetic
Association, Royal College of Nursing and The College of Optometrists. The review
concluded that no changes to the current NICE guideline on falls in older adults are
required as there had not been enough conclusive findings from the research literature
to alter the direction of the current guideline. However, recommendations were made
for more RCTs of exercise based interventions, which adds further to the rationale for
conducting this study. Other recommendations that also support the need for this
research study were for standardised assessment of fear of falling and multi-factorial
assessment; the measurement of psychological factors, including fear of falling, for
evaluation of the efficacy of exercise-based interventions are explored in this study.
14
2.3. Fear of Falling and Falls Efficacy
2.3.1.Definition
Bandura (1989, p. 1175) defines self-efficacy as a person’s “beliefs about their capabilities
to exercise control over events that affect their lives. Self-efficacy beliefs function as an
important set of proximal determinants of human motivation, affect, and action.” Self-efficacy
is also defined as a person’s perceived ability to complete a task or activity successfully (Tinetti
and Powell, 1993). Scales of self-efficacy measure efficacy beliefs concerning factors that
influence the quality of functioning in the selected activity domain. Fall-related efficacy, also
referred to as falls efficacy, is one’s perceived ability to avoid falling.
The Falls Efficacy Scale (FES; Tinetti et al., 1990) was developed as a measure of fear of
falling (FOF), which has been defined as a "low perceived self-efficacy at avoiding falls during
essential, nonhazardous activities of daily living" (Tinetti et al., 1990, p. P239). After one or
more falls or near misses a person at risk of falling may feel that the next fall may have more
serious consequences to either their mental or physiological health. It is this realisation that
may cause them to be more alert to potential hazards, resulting in increased caution when
performing ADLs. Additional caution demonstrated when performing ADLs as a result of a fear
of falling at this level is a reasonable response to the danger of falling. However, a greater fear
of falling may affect the physical and social mobility of the person, as they may avoid specific
activities or situations to avoid falling. Fear of falling can be situational, for example, if a person
was performing a specific ADL at the time of a previous fall, they may associate this ADL with
falling, and therefore develop symptoms of anxiety when they perform this ADL, for example,
elevated heart rate, a shortness of breath, or feeling faint. In an attempt to reduce these
symptoms these lasting concerns can lead to avoidance of performing specific behaviours and
activity restriction despite the individual still being physically capable of performing them
(Tinetti and Powell, 1993). In cases of non-situational fear of falling, rather than avoiding only
the ADLs with which they associate falling persons will avoid other ADLs, even if they believe
that they are capable of performing it. Fear of falling, whether situational or non-situational
can result in a reduction of mobility and activity levels, for example if falls risks are perceived
to be greater outside the house a person with a fear of falling may restrict their activities
outside the house. As such, this reduced level of activity may result in a reduction in physical
health and mobility, for example atrophy of the muscles, and psychological well-being from a
reduction in social interaction. In turn, the reduction in physiological and psychosocial function
caused indirectly by the fear of falling can further increase the risk of falling, and therefore is
an important factor to address in older adults at a high risk of falling.
15
However, there is evidence that fear of falling is not always accompanied by avoidance
behaviours. For example, in a study of 1,064 population-based community-dwelling older
adults by Murphy et al. (2002) only 44% of participants who had reported having a fear of
falling also reported restricted activity levels. The findings from this study also found that
activity restriction was associated with health status, slow timed physical performance,
disability in Activities of Daily Living (ADLs) and poor psychosocial function, and longitudinal
research may be useful in finding any causal relationships between activity restriction and
these factors. An example of research that has examined FOF and falls efficacy as individual
concepts is a RCT of a Tai Chi intervention by Li and colleagues (2005). This study examined the
extent to which falls efficacy regulates FOF by comparing measures of FOF using the Survey of
Activities and Fear of Falling in the Elderly (SAFFE; Lachman et al., 1998) and falls efficacy using
the ABC scale (Powell and Myers, 1995) – an extension of the FES (Tinetti et al., 1990) in a
cohort of older adults recruited from a health system database. The results showed that falls
efficacy increased as a result of the Tai Chi intervention, and that these improvements were
indicated to be an underlying mechanism for the co-existent reduction in fear of falling. Results
from both of these studies could be used to argue that although FOF and falls efficacy may coexist and influence each other, they still require individual measurement as evidence of one
does not necessitate the other.
The FES was developed by Tinetti and colleagues (1990) to expand the FOF concept from
being dichotomous to continuous. In other words, rather than either being either fearful or not
fearful of falling, the extent to which a person is fearful of falling is represented by their degree
of falls efficacy on a continuous scale. However, despite this proposed representation of FOF as
a continuous concept, FOF is still only associated with low falls efficacy. It could be that a
relative degree of FOF should be associated with degrees of falls, as suggested in Figure 2.3.
Falls efficacy scale
FOF scale
High
Low
Low
High
Figure 2.3.: Diagrammatic representation of a continuous scale of fear of falling parallel to a continuous
scale of falls efficacy, i.e.: a high measure of falls efficacy is associated with a lower degree of fear of
falling
16
Lack of disparity between FOF and falls efficacy may have significant effects on how
research findings are interpreted and implemented in the design of falls interventions,
including use of fear of falling and falls efficacy as a predictor of falls risk. Concerns regarding
the broad recommendations for screening and assessment of FOF were expressed in a review
of NICE guideline 21 (2011) by a stakeholder from the Royal College of Physicians (RCP), which
included a recommendation for a revision of the original guideline to include more
standardisation of assessment. If one term was used throughout the literature, outcome
measures and their meaning would be more comparable between research studies. As
discussed below research concerning the influence of fall history on fear of falling and falls
efficacy in older adults has had varying outcomes.
2.3.2.
Prevalence
Fear of falling and avoidance behaviours due to fear of falling are highly prevalent in
community-dwelling older adults (Zijlstra et al., 2007a). Research studies of population-based
samples suggest that between 25% and 54% of community dwelling older adults are estimated
to have a fear of falling (Murphy et al., 2002; Zijlstra et al., 2007a), while over 47% are reported
to have restricted or curtailed activity (Zijlstra et al., 2007a). Between 44% and 66% of older
adults report both a fear of falling and activity restriction (Murphy et al., 2002; Zijlstra et al.,
2007a). While measuring tools for FOF and falls efficacy have been examined for test re-test
reliability in UK-based samples (Kempen et al., 2008; Yardley et al., 2005), there is a lack of
literature reporting prevalence of these modifiable, yet highly influential risk factors in the UK
older adult population.
2.3.3. Implications
Older adults with a history of falling are more likely to develop a FOF than those with no
history of falling (Howland et al., 1998; Murphy et al., 2002; Arfken et al., 1994) – FOF is also
more prevalent in female than male older adults (Howland et al., 1998). FOF is a risk factor for
falling (Cumming et al., 2000) and therefore it is important to assess and manage FOF alongside
other risk factors to reduce risk of falling. Falls efficacy has been found to be independently
correlated with physical and social functioning, undertaking ADLs and independent ADLs (iADLs)
and activity curtailment (Tinetti et al., 1994; Howland et al, 1998; Cumming et al., 2000). It is
therefore understandable that reductions in fall-related efficacy and increased fear of falling
have been associated with deterioration or reduced quality of life in older adults (Arfken et al.,
1994; Cumming et al., 2000; Lachman et al., 1998), frailty (Arfken et al., 1994), as well as
17
impaired function, loss of independence (Cumming et al, 2000) and increased susceptibility to
depression (Arfken et al., 1994; Murphy et al., 2002). Without intervention recurrent falls can
result in cyclical increments in FOF and risk of falling, contributing towards repeated reduction of
quality of life, and decreased physical and social functioning (See Figure 2.4). For example a
history of falling and FOF are risk factors for falls that increase with recurrent falling (Arfken et
al., 1994). However intervention to reduce FOF reduces risk of falling (de Kam, et al., 2009)
which in turn reduces FOF (See Figure 2.4).
Further evaluation of the prevalence of FOF and falls efficacy in the UK older adult
population will enable more informed and effective management of falls. Considering the
prevalence and influence of FOF on such a range of parameters the need for interventions
specifically targeting reduction of FOF in older adults has been highlighted in several studies
(Tennstedt et al., 1998; Cumming et al., 2000).
1st Fall
Recurrent Falls
Reduced
falls
incidence
Increased
FOF
Increased
falls risk
With
Intervention
Without
intervention
Reduced
FOF
Reduced
falls risk
Figure 2.4.: Visual representation of cyclic relationship between falls incidence and FOF, both with and
without intervention to reduce FOF
2.3.4.
Intervention
FOF has been significantly associated with a history of falling and health status (Howland et
al., 1993) and many of the predisposing factors for FOF relate to falls risk (Murphy et al., 2002).
It has therefore been suggested that preventive measures to reduce fear of falling may also
reduce falls risk (Murphy et al., 2002). As such, the NICE guideline (2004, p. 11) states that “Falls
prevention programmes should also address potential barriers such as low self-efficacy and fear
18
of falling”. Other health benefits to older adults resulting from increased falls efficacy through
intervention include improved quality of life, increased ability to perform ADLs and greater
social functioning (Tennstedt et al., 1998; Cumming et al., 2000).
A systematic review of randomized controlled trials by Zijlstra (2007b) identified several
studies of interventions that had found significant reductions in FOF. The review identified a
number of studies showing that home-based exercise, as well as fall-related multi-factorial
programmes and community-based tai chi delivered to groups effectively reduce FOF in
community-dwelling older adults. Interestingly the article also found that only three of the
effective interventions had been targeted specifically towards reducing FOF – evidence contrary
to other evidence-based recommendations of targeted intervention (Tennstedt et al., 1998).
In other findings, Tennstedt and colleagues (1998) reported no reduction in falls risk despite
effectively reducing FOF in a sample of community-dwelling older adults through a targeted
intervention. This lack of reduction in falls risk was attributed to increased activity in response to
the reduced FOF – the overall benefits were identified more as the effects of increased activity
and confidence on quality of life and independence. Findings such as these support the
argument that FOF is independent of falls risk (Maki et al., 1991).
As discussed above, falls efficacy is regulated by many factors, including previous
experiences, such as falls history. By influencing their sense of control, competence and ability in
activities they might perceive to be high risk, falling may determine a person’s belief in their own
ability to avoid falling and thus their motivation to participate in these activities. Motivational
theories, such as self-determination theory and its sub-theories (Deci and Ryan, 1985), propose
different types of motivation and identify different motivational climates that may enhance or
hinder these types of motivation, as discussed in more detail below.
2.4. Self-determination Theory
2.4.1.Overview
Self Determination Theory (SDT) is a motivational theory developed by Deci and Ryan
(1985) comprised of several sub-theories, including Cognitive Evaluation Theory (CET; Ryan
and Deci, 2000). In application, SDT enables the investigation of self-motivation, based on
inherent growth tendencies and innate psychological need (Ryan and Deci, 2000a). SDT
proposes a continuum of different types of motivation which are arranged from left to right
by degree of self-regulation (See Figure 2.5; Hagger and Chatzisarantis, 2007).
19
2.4.2.Types of motivation.
2.4.2.1.
Intrinsic motivation
Positioned on the far right end of the continuum (See Figure 2.5.), intrinsic
motivation has the highest level of autonomy and most intrinsically regulated form of
behaviour of all the motivational types on the continuum. To be intrinsically motivated is
to undertake a particular activity for inherent satisfaction, for example, to exercise for
sheer pleasure, without seeking an external reward (Ryan and Deci, 2000a).
Figure 2.5: Schematic representation of self-determination theory illustrating the features of
three of the component sub-theories: Basic psychological need theory, cognitive evaluation theory,
and organismic integration theory (Hagger and Chatzisarantis, 2007, p. 8).
2.4.2.2.
Extrinsic motivation
Located between intrinsic motivation and amotivation on the continuum (See Figure
2.5), there are four different classifications of extrinsic motivation each varying in their
level of autonomy (Hagger and Chatzisarantis, 2007).
20
2.4.2.2.1.
External Regulation
External regulation is the least autonomous, and therefore the most highly
controlled classification of all extrinsically motivated behaviours (Hagger and
Chatzisarantis, 2007). It is characterised by motivation to meet externally defined
demands, for the purpose of attaining external reward (Ryan and Deci, 2000a;
Hagger and Chatzisarantis, 2007). According to SDT, once external rewards or
demands are absent, the extrinsic motivation to carry out the activity or behaviour
no longer prevails (Ryan and Deci, 2000a; Hagger and Chatzisarantis, 2007). For
example: an externally motivated patient referred by their GP to participate in
exercise classes to reduce their risk of falling might only continue with the classes as
long as they are specifically required to by their GP or the exercise instructor.
2.4.2.2.2.
Introjected Regulation
Introjected regulation of motivation involves a higher level of control than
external regulation, through reward or punishment for performance via internal
contingencies. Those who demonstrate introjected behaviour typically seek external
approval and aim to avoid external disapproval (Hagger and Chatzisarantis, 2007).
The locus of causality for introjected regulation is still perceived to be external and is
not considered to be part of the self, despite the behaviour being internally driven
(Ryan and Deci, 2000a). As an example: a patient whose motivation is regulated
through introjection may only continue to attend an exercise class to avoid feelings
of guilt and attain the approval of friends or family.
2.4.2.2.3.
Identified Regulation
Identified regulation of behaviour is relatively autonomous in comparison to
external and introjected behaviours (Hagger and Chatzisarantis, 2007). Regulation
through identification means that extrinsic behaviours are self-endorsed and
therefore result from the personal value associated with the external goal or reward
(Ryan and Deci, 2000a). An example of a person whose motivation is regulated
through identification would be someone who continues to attend classes because
they identify with the values and purpose of exercise participation.
21
2.4.2.2.4.
Integrated Regulation
Integrated behaviours are the most autonomously regulated of all
extrinsically motivated behaviours (Ryan and Deci, 2000a). These behaviours are
further assimilated with a person’s own life goals and personal values compared
with behaviours regulated through identification (Hagger and Chatzisarantis, 2007).
However, despite being all the more volitional, the behaviours are still separable
from intrinsically regulated cues by the fact that they are not carried out for their
inherent enjoyment (Ryan and Deci, 2000a). For example: a patient whose
regulation of behaviour is integrated is more likely to assimilate the values of the
exercise classes with their own and these become anchored in their own personality
and lifestyle.
2.4.2.3.
Amotivation
Positioned on the far left end of the continuum (See Figure 2.5.) at the low end of
the scale of autonomy, amotivation is a total absence of motivation or intention to carry
out a given action or behaviour and thus there is also no regulation of the behaviour
(Ryan and Deci, 2000a). An example of this is a patient who has been referred to an
exercise programme by their GP or an exercise instructor but has no intention to
participate and therefore does not attend the classes.
2.5. Cognitive Evaluation Theory
2.5.1. Overview
Cognitive Evaluation Theory (CET) is a sub-theory of SDT designed to explain the
different forms of motivation (Ryan and Deci, 2000a). CET states that there are three needs
that must be satisfied to facilitate autonomous motivation; these needs are for autonomy,
relatedness and competence (Hagger and Chatzisarantis, 2007; See Figure 2.5).
2.5.2. Definitions
2.5.2.1.
Autonomy
Autonomy concerns the self-endorsement of one’s actions (Hagger and
Chatzisarantis, 2007) – it is the inherent need to be in control of one’s own behaviour
and actions, as opposed to being controlled by another person or external factor.
22
2.5.2.2.
Relatedness
Relatedness is the innate need to interact with others – this need is most satisfied in
contexts that provide a person with a sense of belonging and connectedness (Hagger
and Chatzisarantis, 2007). Without this sense of relatedness a person is likely to
experience a feeling of alienation and insecurity and therefore they may be less likely to
enjoy or exhibit an interest in a given activity.
2.5.2.3.
Competence
Competence is the inherent need to feel capable of one’s own ability to perform a
particular activity – a similar concept to self-efficacy (Ryan and Deci, 2000a). CET theory
argues that social-contextual events that develop feelings of competence during activity,
for example positive feedback and rewards, can enhance intrinsic motivation for that
activity.
2.6. Linking Self Determination Theory with Cognitive Evaluation Theory
Self Determination Theory (SDT; Deci and Ryan, 1985) enables the identification of different
types of behavioural regulation. These types of regulation are influenced by factors that are
considered in sub-theories of SDT, including the satisfaction of psychological needs for
autonomy, competence and relatedness (Ryan and Deci, 2000a). SDT states that the degree of
self-regulation in a given behaviour (i.e.: whether someone is intrinsically or extrinsically
motivated or entirely amotivated) is partly dependent upon the satisfaction of these three
psychological needs (See Figure 2.5; Hagger and Chatzisarantis, 2007). When exposed to
environments that support satisfaction of these psychological needs more self determined forms
of behavioural regulation (i.e.: intrinsic motivation and internalized forms of extrinsic
motivation) are facilitated. Conversely, when one or more psychological needs are neglected,
these self determined forms of regulation are thwarted, and instead extrinsic motivation and
amotivation thrive.
2.7. Application of theory to exercise for older adults
2.7.1.Self-determination Theory
Evidence has been published to suggest that there are numerous positive effects
resulting from participation in targeted exercise interventions on falls risk factors in older
adults (Gillespie et al., 2009). Understanding the influence of motivation over exercise
behaviour is important in development of effective exercise interventions. It allows
23
investigation of how interventions can be adapted to accommodate for the needs of this
population, and increase motivation and reduce barriers to exercise. SDT is an example of
motivational theory used in exercise domains (Ryan and Deci, 2000a). For example, SDT has
been applied as a theoretical framework for studies investigating overweight and obese
populations (Edmunds et al., 2007) and adolescents (Gillison et al., 2006) to examine
predictive relationships between need satisfaction, autonomy support, exercise motivational
or behavioural regulation and well-being (Edmunds et al., 2007; Gillison et al., 2006).
However, while there has been some, research focusing on the use of SDT to predict and
evaluate exercise behaviours in aging populations is lacking.
Edmunds and colleagues (2006) conducted a study examining how psychological need
satisfaction and motivational regulation relate to and predict exercise behaviour in a sample
of 369 participants aged from 16 to 64 years recruited from fitness, community and retail
settings. The results showed that age was an independent predictor of total exercise
behaviour, along with introjected regulation. It was concluded that SDT can be used to
predict exercise behaviours above those accounted for by demographic characteristics, i.e.:
age and gender (Edmunds et al., 2006). However, the participants used in the research study
are not entirely representative of the general population; the recruitment environments
were limited and thus may have influenced the social demographic groups represented
within the group.
Other studies have looked at how physical activity is associated with motivational
regulation in groups with age-related diseases, such as rheumatoid arthritis and participants
of a cardiac rehabilitation intervention (Hurkmans et al, 2010; Russell and Bray 2010). A
recent study by Hurkman and colleagues (2010) used a postal survey to administer selfreport questionnaires to 271 patients of outpatient clinics for rheumatoid arthritis (mean ±
SD age 62 ± 14). The survey measured current physical activity level, regulation style and
autonomy supportiveness (the amount they feel supported) using the Short Questionnaire
to Assess Health-Enhancing Physical Activity, Treatment Self-Regulation Questionnaire and a
modified version of the Health Care Climate Questionnaire, respectively. The results from
the survey showed that being of a younger age, female, educated to a higher level, having a
shorter disease duration and lower disease activity, and being more autonomously regulated
were all univariately associated with higher reported levels of physical activity. These
findings are in agreement with those of Edmunds and colleagues (2006), who also found
younger age and more intrinsic regulation predicted higher levels of physical activity.
However, these findings may also be influenced by the manner in which participants were
24
recruited – those individuals that responded may represent a proportion of the population
who are generally more autonomously regulated to begin with; amotivated individuals may
be under represented as they are less likely to be motivated to respond to the survey.
Another study of patients of a similar age (mean ± SD age 62.83 +/- 10.78) enrolled in an
outpatient cardiac rehabilitation programme (Russell and Bray, 2010) which measured the
same psychological measures also found that more self-determined motivation was
associated with greater levels of physical activity. However, the study was cross-sectional
which means that it did not allow for the examination of change in the same group of
participants over time; differences that are measured at the various points of progress in the
programme could be influenced by differences in the representational groups rather than a
result of the intervention. In addition, the cross-sectional design allows correlation of
variables to be identified, but it is not possible to establish any causal relationships.
One important limitation of greater volumes of research literature concerning changes
in motivational styles in exercise groups with age-related diseases is that it does not
necessarily accurately represent the general older adult population who may not live with
these specific diseases or conditions. For example, persons with conditions that are more
commonly associated with reduced quality of life, high mortality or morbidity rates, such as
heart disease are also more likely to be motivated to participate in physical activity. In
comparison, relatively healthy individuals with no indication of such illnesses may not be as
motivated to participate in exercise as they do not perceive there to be substantial benefits
to warrant such behaviours. Therefore, there is a need for more research in to the
associations between motivation and exercise behaviour from a SDT perspective in healthy
adult populations.
Researching this gap in the literature is important as the information gained will assist
in meeting recommendations for exercise targeting older adults. For example, the
Guidelines for exercise programming for the frail elderly (2005; See Appendix 2.1.) include
educating participants of the benefits of exercise, implementing goal setting at appropriate
levels, and providing participants with pleasant exercise experiences. All of these
recommendations may be useful to motivate and increase adherence through increased
positive association and experience (Resnick and Spellbring, 2000). These recommendations
are also made in NICE public health guidance 6 (2007) which are discussed in the Section
2.2.3. Such integration of personal values and increased enjoyment in exercise behaviour is
typical of, and therefore should result in, more autonomous regulation (Ryan and Deci,
2000a). Autonomous motivation results in fully volitional behaviours whereas controlled
25
motivation is likely to arise from external pressure and demand and lead to behaviours that
are rewarded externally (Deci and Ryan, 2008). The use of goal setting, integration of values
and education also contribute in part towards satisfying individual need for competence,
relatedness and autonomy, respectively – all of which comprise the basis of Cognitive
Evaluation Theory (Ryan and Deci, 2000a).
2.7.2.Cognitive Evaluation Theory
Individuals with more satisfied needs for autonomy, competence and
relatedness are more likely to experience intrinsic regulation of motivation, while less
satisfaction of psychological needs results in an increased likelihood of experiencing more
extrinsically regulated types of motivation (Ryan and Deci, 2000a). Therefore, research that
is able to identify specific influential factors for need satisfaction in older adults can
contribute towards the development of exercise interventions effective in satisfying these
needs and therefore resulting in more intrinsically regulated motivation.
Being a sub-theory of SDT, theoretical application of CET has been limited. However, due
to the overlapping nature of these two constructs, studies that have examined differences in
need satisfaction associated with exercise or physical activity have also investigated
motivational regulation. For example, as discussed in Section 2.5.3., a study by Edmunds and
colleagues (2006) looked at how motivational regulation and need satisfaction can be used
to predict exercise behaviours. In addition to those findings indicating introjected motivation
as a predictor for physical activity, the study also showed that satisfaction of need for
competence directly predict – and indirectly predict via identified regulation – the amounts
of strenuous exercise undertaken by participants of the study. In addition, in participants
who engaged in organised fitness classes, autonomy support (the perception degree of
autonomy support provided by their fitness instructor) and intrinsic motivation was partially
mediated by satisfaction of need for competence – findings which agree with relationships
suggested by SDT (Edmunds et al., 2007).
Self-efficacy is a theory of motivation similar in concept to the psychological need for
competence (Ryan and Deci, 2000a) and has been applied to exercise behaviour in older
adults. Findings have indicated that in active older adults increased adherence to exercise is
associated with stronger self-efficacy expectations (Resnick and Spellbring, 2000, which
provides further evidence in agreement with CET (Ryan and Deci, 2000a; Ryan et al, 1997) –
suggesting positive relationships between need satisfaction for competence and increased
adherence. When applied to these findings, evidence of a positive relationship between
26
adherence and autonomous regulation (Wilson et al., 2003) could be interpreted to mean
that greater satisfaction of need for competence are associated with more autonomous
regulation in older adults. However, one limitation of the findings from the study by Resnick
and Spellbring (2000) is that the sample is representative of an already active population,
and therefore the findings are not necessarily directly applicable to sedentary or low
physical activity populations about to commence with participation in exercise programmes.
While the research evidence concerning the relationship between adherence and
autonomous regulation by Wilson and colleagues (2003) was based on data from a middleaged sample (mean ± SD age 41.75 +/- 10.75) and therefore may also not be directly
applicable to other adults. These limitations in the research literature highlight that there is
a need for evaluation of pre- and post-intervention need satisfaction in groups of healthy,
community-dwelling older adults.
Resnick and Spellbring (2000) suggested that that adherence is likely to be affected by
beliefs about exercise, benefits of exercise, past experiences with exercise, goals, personality
and unpleasant sensations associated with exercise – factors that are known to influence
motivation (Ryan and Deci, 2000a). Recommendations are made in NICE public health
guidance 6 (2007; see Figure 3.1. in Chapter 3) that reflect on the importance of considering
such influential factors as those identified in Resnick and Spellbring’s (2000) findings.
Behavioural intervention to increase physical activity levels in older adults has been shown
to be highly effective (Conn et al., 2011). A multiple degree of freedom analysis conducted
as part of a recent meta-analytic review of 358 reports examining the effectiveness of
behavioural (e.g., goal setting, contracting, self-monitoring, cues and rewards) and cognitive
(e.g., health education, decision making and providing information) interventional
approaches used to increase physical activity in older adults indicated that interventions
targeting behaviour only, are more effective than any other intervention (Conn et al., 2011).
2.7.3.Linking need satisfaction and behavioural regulation in exercise settings for older
adults
According to SDT and CET greater satisfaction of psychological needs predicts intrinsic
types of motivation – which in turn can predict exercise behaviours (Edmunds et al., 2006).
Individuals who are more intrinsically motivated have been shown to be more likely to
adhere to exercise programmes than extrinsically motivated persons (Wilson et al., 2003).
Therefore, if applied to an older adult population, greater psychological need satisfaction
will be evident in intrinsically motivated individuals who are thus more likely to maintain
27
long-term adherence to exercise and physical activity. They are also more likely to
experience the benefits of exercise which, in an exercise-based falls prevention intervention
setting, includes better functional ability (Resnick and Spellbring, 2000) and reduced FOF (Li
et al., 2005; Zijlstra et al., 2007a). These benefits contribute towards overall improvement in
quality of life, both mentally and physically.
2.8. Quality of Life
2.8.1. Definition
Health-related quality of life (HRQoL) has been defined as “a global indicator of health
resulting from the individual’s perception of the impact that diseases exert on different
spheres of life (physical, mental and social)” (Balboa-Castillo et al., 2011, p. 47) and is
commonly measured in clinical and medical settings. Other psychological definitions exist,
for example, Pavot and Deiner (1993) developed the Satisfaction with Life Scale, which
concerns measurement of well-being that is evaluated based on the individual person’s
weighted criteria of what is important to them in their own life. However, due to its more
frequent use in medical screening and assessment, and particularly as this research thesis
concerns interventions prescribed based on such processes conducted by medical
professionals, the definition of quality of life used herein is refers to health-related quality of
life (HRQoL).
2.8.2. Influential factors
In community-dwelling older adults, reduced physical activity levels and increased
sedentary behaviour are associated with accelerated decline in health-related quality of life
(HRQoL; Brown et al., 2003; Balboa-Castillo et al., 2011). There have been few studies
conducted to specifically evaluate the effects of targeted falls prevention exercise
interventions on HRQoL in the older adult population. One RCT comparing the effects of a
specialised six week balance training intervention with a control condition of a four week
physiotherapy based intervention demonstrated equal improvements in measures of HRQoL
in both treatment groups up to twenty four weeks post-intervention (Steadman et al., 2003).
These results indicate that more time efficient interventions can be implemented in place of
longer physiotherapy-based interventions to result in the same changes in HRQoL outcomes.
High and low fear of falling has been shown to be able to discriminate individuals with better
and poorer HRQoL in community-dwelling older adults over the age of 70 years (Li et al.,
2003) which adds HRQoL to one of the many factors that have been shown to be influenced
28
by fear of falling. The influential effect of falls history on fear of falling (Howland et al, 1998;
Murphy et al., 2002; Arfken et al., 1994) could therefore be interpreted to indicate that falls
history has an indirect effect on HRQoL. There is evidence of direct associations between
falls history and factors that are also associated with HRQoL such as activity restriction and
functional ability (Tinetti et al., 1994; Howland et al, 1998; Cumming et al, 2000); however
there is an absence of research literature to indicate direct links between falls history and
HRQoL. However, a RCT investigating the influence of hip fracture on quality of life in a
cohort of 194 women aged over 75 years and living in the community, all of whom had
experienced one or more fall or one fall that resulted in hospitalisation, highlighted the
profound impact of hip fracture on the quality of life of adults (Salkeld et al., 2000) – an
injury which is most likely to be caused by a fall. The findings from this study showed that
death was preferable to living in a state of health that meant loss of their home,
independence, and most importantly normal quality of life in older women who have
exceeded the average life expectancy (Salkeld et al., 2000). It was concluded that falls and
fractures pose a substantial threat to quality of life in this demographic (Salkeld et al., 2000).
2.8.3.Assessment and Implications
As a function of health-related outcome measures, particularly in clinical or medical
settings where time and cost efficiency are paramount, HRQoL is often assessed through
self-report questionnaires. Measurement of HRQoL in can be used for two purposes within
research studies: for discrimination of individuals according to HRQoL, for example:
identification of participants suitable for inclusion in a study (Lord et al, 2005), and for
evaluation of changes in HRQoL over a given timeframe, for example: before, during and
after completion of an intervention (Steadman et al, 2003).
The Prevention of Falls Network Earth (ProFaNE; Lamb et al., 2005) recommend the
Short Form 12 (SF-12; Ware et al., 1996) and European Quality of Life Instrument (EuroQoL
EQ-5D; EuroQol Group, 1990). Preference of the SF-12 over the EuroQoL in data collection in
previous studies has been based on the SF-12 providing a broader assessment of mental and
physical health than the EuroQoL EQ-5D. The SF-12 is comprised of 12 items, each belonging
to one of eight scales, the responses to their corresponding items – producing two summary
scores for physical and mental health (See Appendix 2.2.). The SF 12 also has a response
format that may be better suited for administration in older adult populations (Lamb et al.,
2005). However, a factor that may be considered in terms of cost to service providers is that
no license fee is required to use the EuroQoL EQ-5D, unlike the SF-12.
29
In clinical and health settings it is commonplace to record factors influential to quality
of life such as previous hip fracture and falls in a patient’s case history. Fear of Falling (FOF)
is also an influential factor for HRQoL (Li et al., 2003) and may be measured using the FES-I
(Yardley et al., 2005) (See Section 2.4.) as part of MFFRA. However, quality of life itself is not
as frequently recorded in a patient history despite growing evidence of its significance in
patient recovery. For example, assessments of quality of life have been used in previous
studies to supplement clinical assessment of chronic health conditions, including cancer
(Goodwin et al., 2003) and arterial diseases (Permanyer-Miralda et al., 1991). Other
influential factors such as activity restriction and functional ability are measurable through
specific items belonging to the scales under the Physical and Mental Health Summary
Measures of the SF-12 (Ware et al, 1996; See Appendix 2.2.). As an example, activity
restriction and functional ability can be assessed through responses to the items concerning
Physical Functioning (PF) and Role-Physical (RP) which are summary measures of Physical
Health (PCS), and Role-Emotional (RE) which is a summary score of Mental Health (MCS)
(Ware et al, 1996) respectively.
2.8.4.Strategy and Policy for Older People in Wales
The Welsh Assembly Government’s Strategy for Older People in Wales (2003) is a
response to over 100 recommendations made in research-based reports regarding the
responsibilities of the government to older adults and published by an Advisory Group in
May 2002, entitled ‘When I’m 64..…or more’. The Strategy for Older People was developed
to address fundamental issues associated with an ageing population in Wales and to
construct relevant and valid policies and programmes to improve provision of health care
and quality of life in later life, while adhering to United Nations Principles for Older Persons
(1991; See Appendix 2.3.). The Principles, which cover the topics of independence,
participation, care, self fulfilment and dignity of older adults, are reflected by the aims of the
Strategy – particularly concerning the promotion of health and well-being in older adults.
For example:
Principle 11: “Older persons should have access to health care to help them to maintain or
regain the optimum level of physical, mental and emotional well-being and to prevent or
delay the onset of illness.”
United Nations Principles for Older Persons (1991 p. 2)
One of the five key aims of the Strategy directly responds to this principle, including
reference to the approaches to be used to address the issue:
30
“To promote and improve the health and well-being of older people through integrated
planning and service delivery frameworks and more responsive diagnostic and support
services”.
The Welsh Government provided £10 million of funding to implement the Strategy
during the first 3 years, which was used in part to develop the National Service Framework
for Older People in Wales (NSF; 2006).
The role of the NSF is to set evidence-based national standards to improve provision of
quality health and social care. Its purpose is also to improve access to these services for
older people across Wales, which include specialist services for Stroke, Falls and Fractures
and Mental Health in Older Adults. The standards set by the NSF (2006) focus on:

Age Discrimination

Person Centred Care

Promoting Health and Well-being

Challenging Dependency

Intermediate Care

Hospital Care

Stroke

Falls and Fractures

Mental Health in Older People

Medicines and Older People
The rationale for the NSF standards in the promotion of health and well-being in older
age are to present a vision of older age that promotes good health, vitality, independence,
and active citizenship, as well as a reduction in the impact of disability and illness on health
and well-being. The key interventions proposed to address this rationale, including the aim
to extend the healthy life expectancies of older adults, are:

Initiatives to address the social, economic and environmental factors that influence
health

Availability of integrated health promotion activities of specific benefit to older
people

Within a conducive environment, providing support for individuals to take more
responsibility for their own health and well-being
31

Offering access to mainstream health promotion and disease prevention
programmes
(National Service Framework for Older People in Wales, 2006)
The proposal that interventions should provide environments that support for older
adults to take responsibility for their own health and well-being links to the importance of
environmental factors on exercise motivation and HRQoL. The emphasis on providing this
type of supportive environment is reflective of the environments that are conducive with
with nurturing more autonomous regulation of exercise behaviours in SDT and CET (Ryan
and Deci, 2000a). Links can also be made between these effects of these environments on
motivational regulation and HRQoL as discussed earlier (See Sections: 2.5., 2.6., and 2.7.).
Current and predicted increases in fall-related health issues paired with a growing
population of older adults means that these recommendations need to be applied to falls
prevention strategies to reduce risk of falling in older adults, and therefore ease the
economic burden on health services for the treatment of fall-related injuries. The planned
actions to implement these interventions between 2003 and 2007 included local community
and health, social care and well-being strategies, specific and accessible health promotion
programmes that are evidence-based and monitored, as well as local commissioning
strategies to ensure the accessibility of primary care services, including exercise referral
schemes along with screening and prevention programmes.
2.8.5.Guidelines and guidance
The NICE public health guidance 16 for mental wellbeing and older people published in
2008 with a specific focus on role of occupational therapy, physical activity walking and
training interventions in promoting mental wellbeing in older adults. The recommendations
for physical activity made in this guidance document include offering individualised,
community-based exercise and physical activity programmes including strength and
resistance exercise, particularly for frail older adults, which also support the NICE 21
guideline (2004) recommendation for strength and balance training for those identified at
risk of falling. Other recommendations made by the NICE public health guidance 16 (2008)
include ensuring that these exercise programmes reflect the preferences of older people,
which links to providing exercise environments that are supportive of need satisfaction
(Ryan and Deci, 2000a). Further recommendations are also made for frequency and duration
of exercise sessions and how to enhance adherence: attendance to sessions at least once or
twice a week and to complete 30 minutes of exercise on five days a week or more, which is
32
concurrent with the recommendations made in the Guidelines for exercise programming for
the frail elderly (2005; See Appendix 2.1) by educating participants on the benefits of regular
exercise and providing examples of ADLs that contribute towards these bouts of exercise, for
example, housework, gardening or shopping. The guidance also recommends encouraging
regular feedback so that motivation of the participants can be monitored. This type of
feedback is instrumental in the development of interventions that provide optimal
environments for achievement of need satisfaction and is conducive for more intrinsic forms
of motivation (Deci and Ryan, 2000a).
2.9. Self-determination Theory, Cognitive Evaluation Theory and Well-being
Greater need satisfaction has been shown to predict more intrinsic types of motivation,
which can be used to predict exercise behaviours (Edmunds et al, 2006), including adherence to
exercise programmes (Wilson et al., 2003). Therefore, the motivational type of an individual can
determine whether or not they are likely to experience the long-term benefits of exercise,
including better functional ability (Resnick and Spellbring, 2000) and reduced FOF (Li et al., 2005;
Zijlstra et al., 2007a), which are contributory factors towards mental and physical quality of life.
Individuals whose exercise behaviours are initially more extrinsically regulated may develop
more autonomic regulation over time as their experiences of exercise and associations with
exercise behaviours changes. For example, the values of exercise that they learn of through
experience and educational elements of interventions become assimilated with their own
personal beliefs about exercise. This means that individuals who have more controlled
regulation of exercise behaviours can become more intrinsically and autonomously motivated to
exercise over time, which results in greater need satisfaction which is influenced by their
exercise environment and experiences associated with exercise. Therefore it is important to
make considerations for individuals with different motivational types when developing exercise
interventions, particularly in older populations as age has a significant influence on motivational
type (Edmunds et al, 2006). Interventions teaching the benefits of exercise, while establishing
appropriate goals and increasing pleasant associations with exercise should improve adherence
exercise (Resnick and Spellbring, 2000).
2.10.
Perceived Competence
2.10.1. Definition
Perceived competence is defined as how an individual describes their own ability in
various domains (Conroy et al., 2007). In a clinical treatment setting perceived competence
has been defined as the “degree to which an individual feels capable of effectively managing
33
his or her health outcomes” (Smith et al., 1995, p. 51). Perceived competence is closely
related to self-efficacy, in that it is also a reference to a person’s perceived ability to
complete a task or activity successfully.
2.10.2. Influential factors
Concepts and feelings about oneself are generally encompassed by the term ‘selfconcept’, which is defined as “the sum of an individual’s beliefs and knowledge about
his/her personal attributes and qualities” (Mann et al., 2004, p.357) and thereby, the
concept of self-perception, including perceived competence, is an equivalent to selfconcept. Evaluation of one’s self-concept is referred to as ‘self-esteem’, and is an important
feature in maintaining positive mental and physical health states (Mann et al., 2004). Health
promotion is the enablement of control and improvement of one’s own health (WHO, 1986),
and enhancement of self-esteem, competence and well-being are key focal points in
processes of mental health promotion (Mann et al., 2004).
CET argues that satisfaction of the psychological needs for competence, relatedness
and autonomy provides a nurturing environment for intrinsic motivation (Deci and Ryan,
2008a). Environments that contribute towards feelings of competence, for example settings
that provide positive performance feedback, also enhance intrinsic motivation during
specific behaviours, including exercise. An early study by Vallerand and Reid (1984) provided
evidence that perceived competence is a mediating factor between positive feedback
regarding performance and increased intrinsic motivation. Moreover in order for intrinsic
motivation to be enhanced, a sense of competence must also be accompanied by a feeling
of autonomy and relatedness (Deci and Ryan, 2000a), hence the theory of CET.
Autonomy-supportiveness in a clinical setting has been shown to influence
effectiveness of self-administered treatment programmes in clinical samples, for example in
diabetic patients (Williams et al., 2004) and cessation of smoking (Williams and Deci, 1996).
Patients have been shown to become more autonomously motivated to adhere to their
treatment programme when autonomy is supported, i.e.: they feel that they are responsible
and capable of managing their own treatment, alongside increased perceived competence in
management of their condition or illness and enhanced self-esteem.
Treatment programmes or clinical environments that facilitate autonomous or intrinsic
motivation have been shown to enhance feelings of perceived competence and self-esteem
in patients (Williams et al., 2004; Williams and Deci, 1996). As such it is possible that similar
findings may be revealed in other clinical environments that also aim to increase intrinsic
34
motivation. For example, measurement of perceived competence in clinical settings, such as
an exercise-based or behavioural falls prevention intervention, alongside measurement of
motivation types or types of behavioural regulation, may support the existing evidence
showing an increase in perceived competence and increased intrinsic behavioural
regulation. Such findings would support the argument for increased or improved training in
creating autonomy-supportive exercise environments for falls clinicians and exercise
professionals who provide care services for fallers (Williams et al., 1998).
Falls interventions aim to decrease measures of FOF, or rather increase self-efficacy in
avoidance of falling. As self-efficacy and perceived competence are similar constructs; it is
possible that a falls intervention programme may in fact produce similar effects on these
two constructs. An increase in perceived competence to continue with an effective selfadministered treatment programme would result in a better quality of treatment than a
reduction in perceived competence, and therefore this may be reflected in improved
measures of HRQoL in patients.
2.11.
Study Rationale
2.11.1. Guideline rationale
NICE guideline 21 (2004) made recommendations for future research that included
identifying the most important and cost-effective components for MMFRI across different
settings and patient groups, measuring the impact of these interventions on falls incidence
and injury and investigating whether individuals who will benefit most from MFFRA and
MMFRI can be identified according to their falls risk. The guideline also made
recommendations for strength and balance training to be used as part of MFFRI; while
specific components and delivery recommendations were made in the Guidelines for
Exercise Programming for the Frail Elderly (2005; See Appendix 2.1.).
2.11.2. Research rationale
Research studies have identified psychological benefits associated with higher levels of
physical activity or exercise in older adults, including better HRQoL (Balboa-Castillo et al.,
2011) and reduced FOF (Zijlstra et al., 2007a). Thus the present study evaluates HRQoL to
identify whether participation in an exercise programme targeting strength and balance in a
fall-prone population can also result in improved mental and physical well-being, and/or
reduce fear of falling.
More intrinsic types of behavioural regulation have been shown to be positively
35
associated with greater levels of physical activity (Edmunds et al., 2006; Hurkmans et al,
2010). The evaluation of behavioural regulation in this study will provide information about
which types of behavioural regulation are associated with fallers, and the effects of an
exercise programme targeting strength and balance on behavioural regulation.
Greater levels of physical activity in older adults have also been shown to be
associated with psychological need satisfaction (Edmunds et al., 2006; Hurkmans et al.,
2010; Russell and Bray, 2010), while feelings of perceived competence (or self-efficacy) in
combination with an increased sense of autonomy are suggested to be associated with
enhanced intrinsic motivation (Ryan and Deci, 2000b). Findings have shown that greater
reported self-efficacy is predictive of adherence to exercise (Resnick and Spellbring, 2000),
which concurs with proposals from CET that satisfaction of the psychological need for
competence is associated with self-determined exercise behaviours. Markland and Tobin
(2004) suggest the consideration of perceived competence in measurement tools; thus this
variable is included in this study.
2.11.3. Overall Rationale
The reason for conducting this study is to fill gaps in the research literature concerning
the effects of exercise interventions on motivation from a SDT perspective, and HRQoL in
community-dwelling, healthy older adults, including fulfilling the research recommendations
made in the clinical and public health guidelines. This study will investigate the effects of a
targeted strength and balance exercise intervention on measures of FOF, need satisfaction,
self-determined regulation, and behavioural regulation of exercise, HRQoL and perceived
competence in older adults at risk of falling. It is hoped that the findings will be able to assist
in understanding underlying relationships between psychological measures including
differences between theoretical subscales over time, i.e.: before and after participation in
the intervention. It is of particular importance to conduct such a study as there may be
implications for identifying psychological measures associated with changes in regulation of
exercise-related behaviours in the development of referral methods used in falls prevention
programmes, such as discrimination of patients who are more or less likely to respond
positively to exercise-based fall prevention interventions based on psychological profile.
2.12.
Chapter Summary
The purpose of this chapter was to review literature concerning the research into falls and
the relationships demonstrated between psychological factors and risk of falling in older adults.
36
The chapter has discussed the definitions and epidemiology of falling in Wales and England, UK –
with a particular emphasis on the demographic characteristics of the population of the county of
Ceredigion, Wales, UK, where the data was collected. The chapter also discussed current
research literature regarding the effectiveness of interventions used to prevent falls and falls risk
factors – with a focus on exercise-based intervention. The chapter went on to outline and
discuss the use of psychological theory in exercise domains and the current state of the research
literature concerning psychological risk factors for falling.
37
Chapter 3: INTERVENTION DESIGN
The purpose of this chapter is to rationalise the intervention examined in this study. The
beginning of the chapter focuses on the influence of research evidence and UK and European
guidelines and recommendations on intervention selection. The chapter then describes the structure
and delivery of the specific interventions examined in the study.
3.1. Intervention Guidelines
Postural Stability Instruction (PSI) courses deliver hospital- and community-based exercise
programmes targeting the reduction of falls and fractures in older adults with a fear or history of
falling (Skelton et al., 2005). A key project in the development of UK and European guidelines
and recommendations for exercise based falls prevention interventions was the Falls
Management Exercise Programme (FaME) by Skelton and colleagues (2005). An evidence-based
12-month intervention was initially designed as part of the FaME project (Skelton et al., 1999) –
activities from which can be found in Appendix 2.1, and a 9-month adaptation of the
intervention later was evaluated using a controlled trial (Skelton et al., 2005). One of the key
conclusions made in the FaME trials was that the rapidly changing evidence base will be likely to
mean that guidelines, such as those from the National Institute for Clinical Excellence (NICE) will
be need to be updated more frequently to stay relevant (Skelton et al., 2005). However, a recent
review of the 2004 guidelines from NICE concluded that there was not enough new evidence
that indicates a need for an update (NICE, 2011). The FaME trials (Skelton et al., 1999) also
helped to form the basis of the recommendations for exercise interventions in the Guidelines for
Exercise Programming for the Frail Elderly published by the European Commission Framework V
Better Ageing Project (2005; See Appendix 2.1). These guidelines along with others will be
discussed in this chapter and Chapter 4 with respect to the design of the intervention examined
in this study, and the research evidence that supports them.
NICE guideline 21 (2004) recommends that multidisciplinary fall interventions should
promote independence, and improve both physical and psychological function, and that further
research into exercise based fall prevention interventions should be conducted using RCT. In
2007, NICE released a guideline on ‘Behaviour change at population, community and individual
levels’ (NICE public health guidance 6, 2007), which targeted the planning, delivery and
evaluation of public health activities that aim to change health-related behaviours. This guideline
makes recommendations that planned interventions targeting behavioural change must be
justified, and that the specific behaviours targeted by the interventions must be identified along
38
with the barriers to change in behaviour. The guideline specifically states that interventions
should support people who find change in health-related behaviour difficult, or lack motivation
to change. Figure 3.1 displays the NICE (2007) recommended actions for delivery of individual
and community-level interventions and programmes.
In a review of the NICE Clinical Guideline for Falls (2004; NICE, 2011) the discussion of
updated research evidence focusing on application of psychological theory to falls prevention
interventions was limited to findings concerning only fear of falling, compliance to interventions
and psychosocial consequences of falling. The comments by stakeholders from the Royal College
of Physicians concerned the development of standardised assessment of fear of falling,
considering the availability of new evidence and the development of international guidelines on
screening and assessment. Although no examples of these new guidelines were listed, their
comment regarding new evidence was supported by the comments from the British
Psychological Society in the review NICE, 2011). These comments concerned the influence of
findings from a RCT study investigating the effect of cognitive-behavioural treatment within falls
prevention programmes on the recommendation for interventions for reducing FOF (Zijlstra et
al., 2009). The findings mentioned in the comments included that, when compared with multicomponent falls prevention interventions that did not address FOF, cognitive behavioural
interventions (including a “booster” session 6 months after intervention completion) resulted in
significant reductions in FOF and activity restriction, alongside a significant increase in daily
activity, significant reductions in recurrent falls and a non significant reduction in tendancy to
seek medical attention relating to falls (Zijlstra et al., 2009). The concluding point was that there
was significant evidence in this study demonstrating the efficacy of targeted psychological
intervention to address FOF (NICE, 2011). The points made in these comments are supportive of
the predictions made by Skelton and colleagues (2005) that the rate of change in evidence will
mean that guidelines and recommendations will become outdated at a faster rate. However,
despite these conclusions the overall decision from the review was that not enough evidence
had been produced since its initial publication to warrant a revision of the guidelines (NICE,
2011).
In addition to the comments made by the stakeholders, it is noticeable that there was no
inclusion of discussion about evidence concerning the effects of falling and intervention on
motivation in the regulation of exercise behaviours, as highlighted in the NICE public health
guidance 6 (2007). The review also did not recommend future investigation the possible links
between changes in regulation of exercise behaviours and fear of falling alongside perceived
quality of life in older adults participating in exercise interventions. As discussed in the Study,
39
this conclusion is a reflection of the limited amount of research applying SDT to exercise
interventions to reduce falls risk, which may be partly responsible for its omission in the review
of the NICE guideline (2011).
Research studies that are able to identify the descriptive reasons of older adults to exercise
or not exercise will provide a basis of information that will assist in development and provision
of motivational exercise environments for older adults. As discussed in the Study Rationale (See
Section 2.9) the need for further evidence evaluating the effectiveness of interventions is
required to develop understanding and support for the most effective interventions for
reducing falls risk factors. There is a lack of evidence focusing on the relationship between
reasons for behaviour from a SDT perspective in exercise domains for older adults, in particular
exercise-based falls prevention interventions.
3.2. Intervention delivery and content
The hospital-based PSI intervention attended by participants was an established
intervention funded and delivered by the local Mid-Wales National Health Service and Age UK
Mid-Wales. Participants were patients who had been referred to the intervention through the
falls clinic held at the local hospital led by a consultant geriatrician this as part of the local falls
prevention service. The intervention used in this study is an adaptation of the original FaME
intervention – tailored according to the specific limitations and needs of the exercise setting.
The fact that the intervention was a part of a pre-established programme implemented by a
local health authority means that the findings from this study may be able to provide practical
evaluation of the programme in terms of effect on behavioural regulation, well-being and FOF.
However, a limitation of the use of an established format such as this is that the intervention
cannot be altered to suit the study design and could limit research questions.
Some of the most confounding influences on the delivery of the programme were limited
funding, transport links and available PSI trained exercise professionals to deliver the courses in
the local area. The effect of these limitations meant that PSI classes were delivered once a week,
rather than twice a week as recommended by the Better Ageing Project (2005).
40
NICE guidelines: Recommendations for delivery of interventions and programmes
Recommended actions for individual-level interventions and programmes
Select interventions that motivate and support people to:
– understand the short, medium and longer-term consequences of their health-related
behaviours, for themselves and others
– feel positive about the benefits of health-enhancing behaviours and changing their
behaviour
– plan their changes in terms of easy steps over time
– recognise how their social contexts and relationships may affect their behaviour, and
identify and plan for situations that might undermine the changes they are trying to make
– plan explicit ‘if–then’ coping strategies to prevent relapse
– make a personal commitment to adopt health-enhancing behaviours by setting (and
recording) goals to undertake clearly defined behaviours, in particular contexts, over a
specified time
– share their behaviour change goals with others
Recommended actions for community-level interventions and programmes
Invest in interventions and programmes that identify and build on the strengths of individuals and
communities and the relationships within communities. These include interventions and
programmes to:
– improve self-efficacy
– develop and maintain supportive social networks and nurturing relationships (for example,
extended kinship networks and other ties)
– support organisations and institutions that offer opportunities for local people to take part
in the planning and delivery of services
Figure. 3.1: Modified version of NICE (2007) recommended actions for delivery of individual and
community-level interventions and programmes
3.3. Chapter Summary
This chapter has discussed the intervention guidelines and guidance publications that have
been used to examined in this study. The beginning of the chapter focuses on the influence of
research evidence and UK and European guidelines and recommendations on intervention
selection. The chapter then describes the structure and delivery of the intervention used in the
study, as well as the limitations and advantages to using a pre-established intervention
programme.
41
Chapter 4: STUDY DESIGN
This chapter forwards the reasoning behind the selection of the structures and measures
implemented in this research study. This includes the influence of various limitations brought about
by the objectives to observe measures changes in participants of a pre-existing intervention.
4.1.
Structure
Due to the ethical issue of withholding treatment from a control group of patients that
would have otherwise have been offered the exercise intervention as part of normal health
service provision a conventional RCT design was not a viable option for this study. However, the
study design used in this study was similar to that of a RCT design used in the FaME trials
(Skelton et al., 2005) whereby the baseline measures of the group were recorded over a 36 week
lead in period prior to commencement of the exercise intervention, and were used as the
control group measures. This method means that it is possible to collect data that is
representative of the study population and all patients are able to receive the treatment that
they are entitled to through the NHS. The authors of the trial also concluded that by adjusting
the patient group to the process of data collection prior to commencement of the intervention,
the likelihood that the data would be affected by the data collection process was decreased.
4.2.
Measures
The National Institute for Clinical Excellence guidelines for ‘Behaviour change at population,
community and individual levels’ (2007) state that interventions should support people who find
change in health-related behaviour difficult, or lack motivation to change and that specific
behaviours targeted by planned interventions must be identified along with the barriers to
change. These recommendations are particularly applicable to older adults – who are more likely
to experience reduced HRQoL as a result of reduced physical activity, and have been
demonstrated to benefit from targeted intervention. For these reasons measures of
motivational regulation are collected as part of this study. It is hoped that through application of
the SDT and CET to participants of an exercise-based falls prevention intervention which has not
yet been explored – alongside quality of life, that it will be possible to identify associations
between specific measures, including subscale measures, that might be useful in identification of
older adults at greater risk of falling, as well as evaluation of the effects of exercise-based falls
prevention interventions in such persons. According to SDT amotivation may be increased by
low perceived competence (Ryan and Deci, 2000b). The rationale for assessing perceived
42
competence is based on a suggestion made by Markland and Tobin (2004) that inclusion of items
measuring lack of perceived competence alongside items measuring amotivation in the BREQ-2
(see Chapter 5) may be a worthwhile addition to existing measures of Amotivation.
4.3. Longitudinal v. cross-sectional designs
A number of factors have limited the number of patients that are able to participate in the
study at any one time. These include:

Limited resources to provide hospital staff and facilities for the clinic to have more
than 5-6 appointments per week

Limited financial resources means that only one fully trained and registered exercise
professional (REP) can be employed to run one PSI training class per week. The
programme has a standardised patient to staff ratio of 4:1, and as there is only one
REP employed in each class this means that the maximum capacity of patients in
each class is four.

Limited numbers of referrals to the clinic from general practitioners each week –
meaning clinic does not have enough appointments to run for the total allotted
time.
For these reasons not enough participants were participating in the intervention to justify
conducting a cross-sectional study. Therefore it was more appropriate to conduct a longitudinal
study, whereby variable data was collected from individual participants before and after the
intervention.
4.4. Research Questions
This study was conducted to investigate the following four research questions:
1. To find out the effects of a targeted strength and balance exercise intervention on
motivation and need satisfaction from an SDT perspective in community-dwelling, healthy
older adults, including fulfilling the research recommendations made in the clinical and
public health guidelines.
2. To investigate the effects of a targeted strength and balance exercise intervention on
measures of FOF, HRQoL and perceived competence in older adults at risk of falling.
3. To use psychological measures to evaluate the effectiveness of a falls prevention
intervention in fulfilment of public health guidelines.
43
4. To develop an understanding of any underlying relationships between psychological
measures including differences between theoretical subscales over time, i.e.: before and
after participation in the intervention.
4.5. Hypotheses
Following completion of a targeted strength and balance exercise intervention it is
hypothesised that there will be
1. Increases in satisfaction of all three psychological needs (need satisfaction for
autonomy, competence and relatedness)
2. Increases in self-determined regulation
a. increases in intrinsic and identified regulation
b. decreases in introjected and external regulation and amotivation
3. Improved well-being (increased mental and physical component QoL )
4. Decreased FOF
5. Increased perceived competence
4.6. Chapter Summary
This chapter has provided justification for the structure, measures and design used in this
study. It has also outlined the research issues that the study addresses, as well as the research
hypotheses of findings by the author based on the constructs of psychological theories and
findings from previous research studies, as outlined in the literature review.
44
Chapter 5: METHOD
5.1. Participants
A sample of fourteen community-dwelling adults aged 68 – 89 years (mean ± standard
deviation 79.8
6.5) was recruited for this study. 11 participants were female and 3
participants were male (see Appendix 6.1). All participants were patients with a history of one or
more falls and resided within the county of Ceredigion in the mid-Wales region (Wales, UK).
Each participant had attended a local National Health Service (NHS) falls clinic service provided
at Bronglais General Hospital, Aberystwyth (Wales, UK) between July 2010 and July 2011 and
had been referred to receive exercise intervention providing that they had met none of the
intervention exclusion criteria (See Figure 5.1) which includes all contraindications for exercise in
such an intervention. Recruitment processes and criteria are described later in this chapter.
Exclusion criteria:










Acute illness
Deteriorating neurological condition
Mini Mental State Examination (MMSE) score <24
Behaviour that creates risk to themselves or others
Un-assessed syncope
Un-assessed low Body Mass Index (BMI)
Uncontrolled tachycardia, hypertension or heart failure
Uncontrolled diabetes or respiratory problems
Uncontrolled pain
Untreated severe osteoporosis – T score > -2.5
Figure 5.1: Exclusion Criteria for falls clinic assessment of patient suitability for referral to attend PSI
classes
5.2. Measures
5.2.1.Falls Efficacy Scale
The original Falls Efficacy Scale is a 10-item questionnaire used to measure fear of
falling and was developed in the USA by Tinetti and colleagues (1990). It was adapted for
international use as the 16-item Falls Efficacy Scale International (FES-I) questionnaire by
the Prevention of Falls Network Europe (ProFaNE) – a research collaboration funded by
the European Commission for use across cultures in different countries and languages
(Yardley et al., 2005). The questionnaire is comprised of 16 items that assess level of
concern about falling when completing activities (See Appendix 5.1). Corresponding
responses to items are made from a four point response scale: 1 = “Not at all
45
concerned”, 2 = “Somewhat concerned”, 3 = “Fairly concerned” and 4 = “Very
concerned”.
A higher score indicates lower falls efficacy, which is interpreted to mean an
increased fear of falling. In contrast, a lower score indicates greater falls efficacy which is
interpreted to mean a limited or absence of fear of falling. The FES-I has demonstrated
cross-cultural validity; scores are associated as expected with age, sex, falls history and
fear of falling and it has also been suggested that the FES-I can discriminate between
sub-groups better than the original 10-item FES scale (Kempen et al., 2007). In a crosssectional study where the 16-item FES-I was completed by 704 older adults aged
between 60 and 90 years its internal reliability (Cronbach’s alpha coefficient = 0.96) and
test-retest reliability after one week (Intra-Class Coefficient (ICC) = 0.96) were both
shown to be excellent (Yardley et al., 2005). These results were suggested to indicate
that the FES-I also performs better than the original FES when identifying concerns
relating to social activities and demanding outdoor balance related tasks, and
particularly when evaluating fear of falling in community-dwelling populations (Yardley
et al., 2005). Another study of the structure of both the 16-item and 7-item versions of
the FES-I indicated strong internal reliability (Cronbach’s alpha coefficient = 0.79;
Delbaere et al., 2010).
5.2.2. Psychological Need Satisfaction Scale
The Psychological Need Satisfaction Scale (PNSS) is a questionnaire to measure need
satisfaction for autonomy, competence and regulations originally developed by
Markland and Tobin (2009) for a study reporting measures of need support and
behavioural regulations in exercise referral scheme clients. The PNSS has nine items (See
Appendix 5.2). The PNSS is comprised of three subscales which are the needs for
autonomy, competence and relatedness. The response scale for the PNSS is comprised
of five numerical responses ranging from 0 to 4 with a corresponding scale of three
descriptive items: 0 = “Not true for me”, 2 = “Sometimes true for me” and 4 = “Not at all
true for me”.
The numerical responses that do not correspond with a descriptive response
indicate a response that is not described on the scale, but falls between the responses –
such that: 1 = a response between “Not true for me” and “Sometimes true for me”, and
3 = a response between “Sometimes true for me” and “Not at all true for me”.
46
The score belonging to each subscale represents the satisfaction of that need for the
respondent, for example, a high score for autonomy indicates high need satisfaction for
autonomy. According to CET, the greater need satisfaction is for all three needs the
more likely it is that behaviours are self-regulated (Deci and Ryan, 2000a). Measures of
reliability were reported in the results of the study for which the PNSS was developed
(Markland and Tobin, 2009); however measures of validity were reported. The authors
concluded that the reliabilities of these subscale measures were adequate, despite low
Cronbach’s alphas reported for Autonomy at 0.59 and Competence at 0.69 (Markland
and Tobin, 2009).
5.2.3. Behavioural Regulation in Exercise Questionnaire
The Behavioural Regulation in Exercise Questionnaire v2 (BREQ-2) is an instrument
for measurement of the degree of self-determination (Markland and Tobin, 2004). The
BREQ-2 is comprised of 19 items (See Appendix 5.3). There are five subscales to the
BREQ-2: Amotivation, External Regulation, Introjected Regulation, Identified Regulation
and Intrinsic Regulation.
The response scale for the BREQ-2 is identical to the PNSS, and is comprised of five
numerical responses ranging from 0 to 4 with a corresponding scale of three descriptive
items: 0 = “Not true for me”, 2 = “Sometimes true for me”, 4 = “Not at all true for me”
The numerical responses that do not correspond with a descriptive response indicate a
response that is not described on the scale, but falls between the responses – such that:
1 = a response between “Not true for me” and “Sometimes true for me”, and 3 = a
response between “Sometimes true for me” and “Not at all true for me”.
The BREQ-2 can be used to either give separate subscale scores, or as an individual
index by calculating a Relative Autonomy Index (RAI) by weighting each subscale. Scores
for the subscales indicate the degree to which a respondent feels self-determined in
their behavioural regulation. For example, a high score for amotivation indicates that the
respondent is amotivated to perform a given behaviour, particularly if accompanied by a
low score in a subscale for more self-determined regulation, such as intrinsic regulation,
while a low RAI is an indication of lower self-determined regulation of behaviour, and
vice versa. Markland and Tobin (2004) reported good validity and reliability; Cronbach’s
Alpha for amotivation at 0.83, external regulation at 0.86, introjected regulation at 0.8,
identified regulation at 0.73 and Intrinsic regulation at 0.86 were all reported in a group
of respondents from an exercise referral scheme.
47
5.2.4. Perceived Competence Scale
The Perceived Competence Scale (PCS) is a short questionnaire that assesses feelings
of competence a specific setting – in this case it is used to measure competence about
participating in a physical activity regularly. The PCS has four items (See Appendix 5.4).
The PCS has no subscales – the only score calculated from items is the mean of all
responses. The response scale for the PCS is identical to the BREQ-2 and PNSS, and is
comprised of five numerical responses ranging from 0 to 4 with a corresponding scale of
three descriptive items: 0 = “Not true for me”, 2 = “Sometimes true for me” and 4 = “Not
at all true for me”.
The numerical responses that do not correspond with a descriptive response
indicate a response that is not described on the scale, but falls between the responses –
such that: 1 = a response between “Not true for me” and “Sometimes true for me”, and
3 = a response between “Sometimes true for me” and “Not at all true for me”.
The means score from the responses to all four items is representative of perceived
competence in a given activity, in this case regulation of exercise behaviour. A higher
score represents greater perceived competence in the respondents. A study by Williams
and colleagues (1998) reported Cronbach’s alpha of 0.84 - 0.87 in a group of diabetes
patient respondents who repeated the questionnaire 3 times over the course of 12
months regarding their perceived competence to regulate their glucose intake. The
authors of this study reported excellent internal consistency (Williams et al, 1998).
5.2.5.Short-form SF-12v.1
The SF12 is an adaptation from the 36-Item Short-Form Health Survey (SF-36; Ware,
2000) developed for administration under time limited, large scale health monitoring
settings. It is recommended for measurement of HRQoL in older adults by ProFANE
(Lamb et al., 2005). The SF-12v.1 is comprised of 12 items (See Appendix 5.5). The SF12
has two summary scores, mental health (MCS) and physical health (PCS), each with four
individual scales: physical function (PF), role-physical function (RF), bodily pain (BP), and
general health (GH) for PCS, and vitality (VT), role-emotional function (RE), social
function (sF), and mental health (MH) for MCS. Each item belongs to one of these
subscales as shown in Table 5.1 below:
48
Summary score
PCS
MCS
Individual scale
Item numbers
PF
2 and 3
RP
4 and 5
BP
8
GH
1
VT
10
RE
6 and 7
SF
12
MH
9 and 11
Table 5.1: SF-12v.1 individual scales and their corresponding item numbers
There are multiple response scales for the SF-12v.1 which is shown in Appendix 5.5.
Each response scale belongs to items of the same subscale. Scores for PCS and MCS are
calculated from item responses using the QualityMetric Health Outcomes Scoring
Software 4.0. A high PCS or MCS score indicates better physical or mental health than a
low score; higher scores are interpreted to indicate a better quality of life, in particular
when reported together. In a previous study of United States (US) and United Kingdom
(UK) general population samples test-retest reliability of the summary score for PCS was
0.890 in the US and 0.864 in the UK population samples and coefficients of 0.760 and
0.774 were found in the US and UK population samples respectively (Ware et al., 1996).
The same study also found that PCS and MCS scores always made the same
discrimination of respondents in to groups. The subscale responses used in this study for
item 12 of the SF-12v1 which belongs to the SF scale for the MCS score is not the same
as the standardised version: the options in the standardised questionnaire for this item
do not include the response option for “A good bit of the time”.
5.3. Procedures
5.3.1. Recruitment
Potential participants were identified from patients referred from the weekly falls
clinic at Bronglais General Hospital, Aberystwyth, Wales, UK to receive an individualised
exercise intervention targeted at improving strength and balance. The patients were
screened for falls risk and suitability for the exercise programme during the clinic, and
referred to attend their first exercise class within a week of attending the clinic (or as soon
as possible); the exercise intervention included six classes of hospital-based Postural Stability
49
Instruction in a group exercise setting and individualised prescribed home exercises (PSI).
Participants were recruited according to specific exclusion criteria: any patients with one or
more of these criteria were not considered for participation (See Table 5.1.). Patients
deemed eligible for participation received information packages about the research study
during their attendance at the falls clinic (See Appendix 5.6).
Patients were advised to read the information thoroughly and to contact the research
team prior to attending their first exercise class if they wished to participate in the study, or
find out more about it. These patients were asked to register their interest in participating in
the study before commencement of the exercise intervention via telephone (using the
contact details provided in the package). For patients unable to respond via telephone
communication was maintained through letter. When contacting the research team, once
any questions had been answered regarding the study, a first appointment was made for the
volunteers to visit the research laboratory to familiarise themselves with the research
procedures, and to ask any further unanswered questions. Once satisfied that they
understood the purpose and what was required of them in the study procedures, informed
consent was gained from each participant (See Appendix 5.6) which was also verified by a
staff member of the research centre who was not associated with the study. Formal ethical
approval was obtained for the study from NHS and institutional ethics committees. During
the same appointment, and once informed consent had been gained from the participant
the first data collection point (DCP 1) took place.
5.3.2. Data collection
Participants completed the five questionnaires described above at two points during
their participation in this study. DCP 1 took place immediately after informed consent was
given by each participant prior to commencement of their first PSI exercise class (or as soon
after commencement as possible). The second data collection point (DCP 2) took place as
soon as possible after participants had attended their sixth and final PSI exercise class. A
flowchart presenting the order of procedures in data collection is shown in Appendix 5.7.
Four questionnaires were administered to each participant in a randomized order during
DCP 1 and DCP 2. During each of these data collection points the questionnaire items and
possible responses were each read aloud to the participant with copies of the questionnaires
in front of the participant (see Appendix 5.7). Participant responses to the items were
recorded by the researcher onto the copy of the appropriate questionnaire. Individual scores
for subscales were then calculated and these along with all item responses were then
50
entered into a Microsoft Excel spreadsheet ready for analysis.
Data presented in this thesis are preliminary, as they form part of a larger study that
includes measurement of other variables, including physiological and biomechanical data
over a longer timeframe; these other findings will be disseminated elsewhere once data
collection is complete.
5.3.3. Data Analysis
Whilst not included in the analysis of data, descriptive data was also produced using
Microsoft Excel 2007 (Excel; Microsoft Corporation, Redmond, WA), and Pearson’s
Correlation between pairs of each of the means and subscale means compare correlations
between DCP 1 and DCP 2 (See Table 6.2). The analysis of data was conducted using the
Statistical Package for Social Sciences (SPSS) (version 18.0; SPSS, Inc., Chicago, IL). The data
was analysed using paired t-tests (95% confidence interval) to compare mean scores for all
subscales of the BREQ-2 (amotivation and extrinsic, introjected, identified and intrinsic
regulation) and PNSS (need satisfaction for autonomy, competence and relatedness)
between DCP 1 and DCP 2, as well as mean scores for the FES-I and PCS. Reliability was
assessed using Cronbach’s alpha (See Table 6.1), and z-scores for skewness and kurtosis of
each subscale of each questionnaire were also calculated. Rationale for use of statistical
tests is reported alongside the results (See Chapter 6).
51
Chapter 6: RESULTS
6.1. Descriptive data
Fourteen participants were involved in this study, 11 of whom were female and 3 who were
male. The mean age of participants in the study was 79.8 (SD 6.5) years with an age range of 68
– 89 years (See Appendix 6.1). All participants had fallen at least once during the six months
prior to commencement of the exercise intervention as this was a criterion for inclusion in the
recruitment process. Appendix 6.1 displays participants’ descriptive data – participant
descriptive are divided into two tables according to falls history. Those who had experienced one
fall are presented in the first table and those who had fallen more than once during the six
month period prior to attending the first of the exercise sessions are presented in the second
table (See Appendix 6.1). Also displayed in these tables are the fall incidence of each participant
and the means and standard deviations (SD) of subject for falls incidence and absence during the
intervention period. Mean number of weeks taken to complete all six exercise sessions, mean
number of absences recorded, mean number of falls between DCP 1 and DCP 2 and mean
number of exercise sessions completed were greater in participants who had experienced more
than one fall during this six month period were also included in the tables. The means, standard
deviation and Cronbach’s alpha coefficients, to test reliability, for each subscale are presented in
Table 6.1.
6.2. Data cleaning
6.2.1.Reliable data
While there is no commonly agreed cut-off for the Cronbach’s alpha coefficients
generally 0.70 and above is acceptable (Nunnally, 1978). Cronbach’s alpha coefficients for
the BREQ-2 and the PCS were all above 0.70, apart from the subscales of the BREQ-2
measuring identified regulation (0.52) and amotivation (0.51). These subscales were still
included in the analyses, as a low alpha might not indicate poor reliability for several
reasons. Firstly, a low alpha in a study design where the pre-test data is used as a baseline
measure may be caused by subjects who have not been exposed to the test content
randomly guessing their responses to items – in this instance, a judgment of instrument
reliability based on pre-test data may be premature (Chong, 1993). Secondly, it is a common
misconception to accept a high alpha as an indication of variance in a single dimension. A
high overall alpha does not necessarily imply the absence of multiple latent dimensions, as it
does not require variance to be shared between all items, and as such a low overall alpha
52
may indicate the existence of latent constructs (Chong, 1993). Opportunities to further
investigate and modify scales to improve internal consistency may be overlooked if
subscales are excluded from analyses based solely on a low alpha mean, and while it is not
claimed that either of these are necessarily explanations in this instance, a decision to
exclude the collected data based only an alpha scores is not robustly supported here. Hence,
these subscales measuring identified regulation and amotivation in the BREQ-2 were still
included.
6.2.2.Non-reliable data
The alpha coefficient for psychological need satisfaction for autonomy measured by
the PNSS was 0.25, indicating an extremely low reliability, and it is extremely unlikely that
any of the alternate explanations described above (see section 6.2.2) can account for such a
low alpha, therefore this subscale was excluded from the analyses.
6.3. Assumption testing
6.3.1.Normal distribution
Normality of distribution of data (ND) was tested by calculation of z-scores for
skewness and kurtosis on all subscales of each questionnaire. Z-scores between ±3 represent
normally distributed data; the only subscale which did not meet this assumption was the
subscale of the PNSS measuring psychological need satisfaction for competence in week 0
(DCP1). However, as there was only one measure that did not meet the assumption of
normal distribution this data was not excluded from the analysis. Non-normal distribution of
data could be attributed to the sample being from a clinical setting; item and subscale
responses from a clinical sample may differ from what might be expected from a non-clinical
sample (Vickers, 2007).
6.3.2.Homogeneity of variance
Variance was testing using Levene’s test. The differences between variances in each
subscale at DCP1 and DCP2 were all non-significant (P > 0.05), and therefore the assumption
of homogeneity of variances was accepted.
6.4. Correction methods
Post-hoc procedures were used in this data analysis. The Bonferroni correction method was
used to control familywise error (i.e.: reduce Type I error – believing there is an effect when
there is not). However, the trade-off for increased control of Type I error rate is a loss of
53
statistical power, and therefore increased likelihood of conceding a Type II error, i.e.: believing
there is no effect when there is).
6.5. Rationale for paired t-tests
Separate paired t-tests were chosen over multivariate analyses (MANOVA). The power
of a MANOVA is dependent on the strength of correlation between dependent variables and
effect size (Field, 2009). Preliminary analysis of Pearson’s Correlation between subscales
identified only seven significant correlations of the sixty correlations of dependent variables
tested; thus predicting low power if a MANOVA was conducted using this data. In addition, a
lack of significant correlations between these dependent variables also mean that analysis
using MANOVA are not theoretically justified, and therefore significance found through such
(heuristic) analyses may not be empirically meaningful.
In order to maintain an acceptable level of degrees of freedom and to increase
likelihood of meeting the assumption of homogeneity of covariance it is suggested that
there must be a ratio of at least 3 subjects to every dependent variable (Vincent, 2005). In
this study, there are 14 subjects and 5 dependent variable measured (i.e.: BREQ-2, PNSS,
FES-I, SF-12 and PCS), which means that the subject-to-dependent-variable ratio is 2.8. As
the ratio is under 3 to 1 the power of MANOVA is limited, thus the use of MANOVA is not
supported.
6.6. Analysis of data
6.6.1.Perceived Need Satisfaction Scale
There was mixed support for hypothesis 1 that there would be Increases in satisfaction
of all three psychological needs (need satisfaction for autonomy, competence and
relatedness). As discussed above, the subscale showing psychological need satisfaction for
autonomy was excluded from analyses due to poor reliability (low Cronbach’s alpha
coefficient). Paired t-tests showed a significant increase in need satisfaction for relatedness
(t(13) = -2.896, P <.025; with Bonferroni Correction) between data collection points which
supported the hypothesis, while there was no significant change in need satisfaction for
competence t(13) = -2.578, P >.025), which disagreed with the hypothesis.
54
Figure 6.1.: Changes in mean scores for subscales of need satisfaction before and after intervention.
6.3.2.Behavioural Regulation in Exercise Questionnaire
Based on an adjusted significance level of .01 using Bonferroni Correction, the paired ttest showed non-significant increases in identified (t(13) =-.433, P >.01) and intrinsic
regulation (t(13) = -.733, P >.01), which supported the directional changes predicted in
hypothesis 2.a. The paired t-test also showed non-significant reductions in amotivation
(t(13) = .402, P >.01), as well as external (t(13) =1.003, P >.01) and introjected regulation
(t(13) =.786, P >.01), which supported the directional changes predicted in hypothesis 2.b.
An increase in Relative Autonomy Index (RAI) was also found between data collection points
and was also non-significant (t(13) = -.911, P >.01).
6.3.3.Short-form SF-12v.1
The paired t-tests showed no significance (based on a Bonferroni corrected significance
level of .025) in the differences between data collections points for either PCS (t(13) = -.639,
P > .025) or MCS (t(13) = -1.165, P > .025); however both scores increased between data
collection points and therefore the directional changes were predicted in hypothesis 3.
55
Table 6.1: Group subscale means and standard deviation
Cronbach's
Alpha
PNSS Autonomy
Mean
1.68
DCP 1
±
±
PNSS Competence
3.68
±
2.61
1.68
±
1.14
0.71
PNSS Relatedness
2.78
±
1.06
3.13
±
1.22
0.74
Perceived Competence Mean Score
4.49
±
1.58
4.82
±
1.90
0.94
BREQ-2 Amotivation score
0.52
±
0.63
0.52
±
0.63
0.51
BREQ-2 External Regulation
1.22
±
1.06
1.22
±
1.06
0.83
BREQ-2 Introjected Regulation
1.84
±
1.16
1.84
±
1.16
0.77
BREQ-2 Identified Regulation
2.84
±
0.84
2.84
±
0.84
0.52
BREQ-2 Intrinsic Regulation
2.26
±
0.97
2.26
±
0.97
0.75
BREQ-2 RAI
7.17
±
5.40
7.17
±
5.40
SF-12 MCS
46.55
±
13.03
49.68
±
14.35
SF-12 PCS
34.05
±
9.77
35.91
±
8.62
FES-I
38.79
±
9.28
34.64
±
10.15
SD
1.08
Mean
3.11
DCP2
±
±
SD
1.97
0.25
Mean refers to mean group score
± SD refers to Standard Deviation
Cronbach's Alpha is calculated from all item responses for each subscale
56
Table 6.2: Pearson’s Correlation
Subscales
PNSS
Competence
PNSS Relatedness Perceived
Competence
mean score
0
6
0
6
0.68**
0.60*
FES-I
Week
Perceived Competence
mean score
0
0.37
6
-0.34
FES-I
-0.05
0.15
0.23
0.42
-0.14
0.04
BREQ-2 Amotivation
Regulation score
BREQ-2 External Regulation
score
BREQ-2 Introjected
Regulation score
BREQ-2 Identified
Regulation score
BREQ-2 Intrinsic Regulation
score
BREQ-2 RAI
-0.23
-0.52
-0.18
-0.55
-0.26
-0.57
-0.41
-0.16
0.20
0.06
0.22
-0.21
0.34
-0.24
0.23
0.12
0.27
-0.21
0.36
-0.45
0.04
0.59*
0.57*
-0.10
-0.31
0.62*
-0.42
-.305
.014
SF-12 Mental Component
Score
SF-12 Physical Component
Score
0
SF-12 Mental
Component Score
6
SF-12 Physical
Component Score
0
6
0
6
-.350
-.276
-.443
-.471
0.04
.079
-.257
.403
.008
0.00
-0.32
-.338
.173
.106
.313
0.39
0.47
0.19
-.222
.165
-.184
.084
0.26
0.70**
-0.13
0.10
.324
.104
.167
-.241
-0.14
0.34
0.11
0.44
.128
.121
.033
-.145
-0.02
0.701*
*
0.53
0.29
0.28
-0.11
0.39
.356
.024
.129
-.337
.398
-.125
-.107
-.058
-.060
.095
.219
.226
-.017
.103
N = 14
*P < 0.05
** P < 0.01
57
6.3.4.
Falls Efficacy Scale International
A reduction in mean FES-I scores between data collection points (t(13) = 1.661, P > .05) was
consistent with hypothesis 4; however, these results were non-significant.
6.3.5.
Perceived Competence Scale
The paired t-test showed a non-significant increase in PCS between data collection points
(t(13) = -0.546, P > 0.05); directional change was consistent with hypothesis 5.
58
Chapter 7: DISCUSSION
The purpose of this chapter is to discuss the key findings from the study, and to relate them to
previous findings from other studies, including those discussed in the literature review. The chapter
then moves on to outline the limitations of the study, followed by proposed clinical, theoretical and
research implications of the findings.
7.1. Key Findings
The aims of this study were to examine changes in a range of psychological parameters in
participants of an exercise intervention targeting older adults with strength and balance deficits
and a history of falling. It was intended that implications of the findings could include
identification of modifiable psychological risk factors and benefits that could be used to
discriminate between and evaluate benefits for different individuals. The purpose of this study
was to address the four research questions as outlined in Section 4.4.
Results supported only one of the hypotheses with a significant increase in psychological
need satisfaction for relatedness, which supported hypothesis 1. However, all predictions of
directional change in each measured construct named in hypotheses 1-5 were met, apart from a
non-significant decrease in psychological need satisfaction for competence which did not
support the directional change predicted in hypothesis 1. The findings showed a non-significant
decrease in FOF, and non-significant increases in both subscales for mental and physical HRQoL,
as well as increased PCS. Thus the results from this study show that over the duration of a 6
week exercise-based strength and balance training programme in healthy older adults
satisfaction of the psychological need for relatedness increases, but all other changes in FOF,
PCS, BREQ-2 and HRQoL variables were non-significant.
Although direct causality cannot be inferred from these results, they partly concur with
changes proposed on the basis of SDT and CET predictions that as an individual’s psychological
needs are satisfied they become more intrinsically motivated (See Figure 2.5; Hagger and
Chatzisarantis, 2007; Ryan and Deci, 2000a). However, SDT and CET also propose that in order
for an increase in intrinsic regulation to occur satisfaction must be achieved for all three
psychological needs (i.e.: autonomy, competence and relatedness; Hagger and Chatzisarantis,
2007). In this study, only two of the subscale measures were reliable for use in the analysis of
data (i.e.: competence and relatedness). The change in relatedness need satisfaction between
data collection points did support previous findings and predictions made by SDT and CET
(Edmunds et al., 2006), but the change in the psychological need satisfaction for competence did
59
not support those initially proposed.
The decreased psychological need satisfaction for competence did not support findings from
previous studies on which the hypotheses were based (Edmunds et al., 2006). However, this
could be partly explained by differences in sample populations between this and previous
studies, such as age (Gillison et al., 2006) and physical condition (Edmunds et al., 2007; Russell
and Bray, 2010). One of the reasons for conducting the present study is that there has been little
research into the effects of exercise on psychological need satisfaction in healthy older adult
populations, or in older adult fallers. The majority of research on adult populations has
investigated effects in groups suffering from specific diseases, and therefore these findings
cannot be extrapolated directly to older populations who are not affected by these specific
diseases.
Another explanation for the reduction in satisfaction of the psychological need for
competence may be the way in which participants are challenged during the exercise classes,
which have a particular emphasis on functional skills that are used in ADLs, including walking and
reaching. It may be that weaknesses and inabilities are exposed in the participants, who may
have developed alternative methods or avoidance strategies in these ADLs, perhaps without
even recognising these adaptations themselves. To be observed by their instructor and fellow
attendees in the exercise classes potentially exposes these weaknesses to the individual,
whether or not they were initially aware of them. Depending on their level of ability to complete
the ADLs and the level of relative difficulty of the tasks set in the classes the participants will feel
either that their psychological need for competence is supported or thwarted in the exercise
environment. The results from this study indicate that the participants have experienced a
reduction in psychological need satisfaction for competence, rather than an increase, which
could indicate that they have indeed felt that their exercise environment has more thwarted
than supported their psychological need for competence. Whether or not satisfaction of their
psychological need for competence is valued by the participants, CET proposes that a reduction
in satisfaction of any of the psychological needs may have a negative influence on selfdetermined regulation of behaviour (Hagger and Chatzisarantis, 2007), and therefore could
result in less intrinsically motivated behaviours reported in the BREQ-2 data. However, this
particular relationship was not investigated in this study, and only a non-significant increase was
found in intrinsic regulation. This could be explained by the concept that all three psychological
needs (i.e.: for autonomy, competence and relatedness) must be satisfied before regulation of
behaviour becomes more self-determined (Hagger and Chatzisarantis, 2007).
As discussed in section 2.8.2, in combination the conceptual similarities between self-
60
efficacy and psychological need for competence, and the research evidence demonstrating a
positive relationship between self-efficacy and exercise adherence in older adults, may lead us
to predict a positive relationship between satisfaction of the psychological need for competence
and adherence. However, if applied to this data it would seem that the reduction in satisfaction
of the psychological need for competence may suggest a reduction in adherence to exercise. In
contrast, although not significant, the directional changes in behavioural regulation, i.e.:
increased intrinsic types, and reduced extrinsic and amotivational types of regulation in this
group provide evidence against this prediction. However, adherence data is not included in the
analysis for this study, but should be considered in similar future research projects to fully
explore this prediction.
Based on the reliability of subscales in the BREQ-2 in comparison to those in the PNSS, of
which one subscale was removed from the analysis, it seems more likely that the finding of
decreased satisfaction of psychological need for competence is due to an issue with the
measurement tool (PNSS), as opposed to an actual change in the variable caused by the
intervention. This change could be due to a number of extraneous variables that require further
investigation, including poor reliability of the subscale measure, and deviation from normal
distribution in the measure of satisfaction of need for competence in week 0 (DCP1; see sections
6.2.1 and 6.3.1).
It is possible that the explanations for the reduction in satisfaction of need for competence
could be also used to explain the non-significant results for FOF, PCS and SF-12 scores. It is
possible that by increasing awareness of their weaknesses in performance of ADLs and falls
avoidance strategies, participants’ perception of their competence in these tasks was negatively
influenced, which may explain why hypothesis 5 was not supported. By increasing their exposure
to risk of falling through participation in challenging exercises as part of the exercise programme,
it may be that as the participants’ decreased in competence need satisfaction, they also became
more aware of the likelihood that they may fall in some settings identified in the items belonging
to the FES-I. It is possible that this may be an influential factor as to why no significant increase
in fear of falling scores was shown in the FES-I scores. However, even if the lack of significance in
changes in fear of falling are influenced by such exposure of weaknesses, this is merely a
speculative comment, as this study did not investigate the links between measures and items of
each subscale in detail. However, the correlations between FOF and both PCS and SF-12
measures were all non-significant, which means that little evidence could support this proposed
explanation.
The lack of a significant change in SF-12 components could also be due to a difference
61
between participants in the importance of managing their falls risk in order to maintain or
improve their mental and physical quality of life. Some subjects may have initially been unaware
of their own functional limitations until participating in the exercise intervention, perhaps not
considering it to be a negative influence on their quality of life, and in turn their perception of
their quality of life may have been quite high initially. It is possible that through the evaluation of
their falls risk, and practice in falls avoidance strategies at the exercise classes over the 6 weeks
that they experienced some negative changes in their perceived competence in their falls
efficacy and their ability to manage their treatment (although not significant – as the findings
show).
7.2. Study limitations
7.2.1.Reliability
7.2.1.1.
Perceived Need Satisfaction Scale
Poor reliability of the subscale measuring satisfaction of the psychological need for
autonomy in the PNSS was apparent by a low Cronbach’s alpha, even when an item was
removed from the analysis. Poor reliability of this subscale has been noted in previous
research (Markland and Tobin, 2009), and the low reliability found in the present study
could partly explain present findings of a significant reduction in satisfaction of the
psychological need for competence, which does not support SDT and CET proposals
given the non-significant changes seen in self determined behavioural regulation. A
limitation caused by excluding this construct is that the data may not be comparable
with findings from other studies that measured and analysed the satisfaction of all three
psychological needs (i.e.: autonomy, competence and relatedness).
An additional problem with PNSS is the way in which all the items in this
questionnaire refer to the exercise classes in the past tense, for example, in item two “I
felt confident that I could do the class”. The terming of the items in the past tense may
explain in part the issue of reliability of the autonomy subscale in the PNSS, as the study
is designed so that this questionnaire is completed before subjects attend their first
exercise class and therefore these items are meaningless to the subjects until they have
attended at least one exercise class.
7.2.1.2.
Behavioural Regulation in Exercise Questionnaire-2
The subscales of the BREQ-2 measuring identified regulation and amotivation both
had a Cronbach’s alpha of less than 0.70, demonstrating low reliability. However,
62
judgment of instrument reliability based on pre-test data and acceptance of a high alpha
as an indication of variance only in a single dimension may both be premature or
erroneous (Chong, 1993), thus these subscales were kept in the analysis. It was hoped
that this decision provided opportunities to identify ways to improve internal
consistency of these measures rather than disregard them altogether.
7.2.2.Response items for SF-12
Another limitation in this study was the use of a modified response scale for item 12 of
the SF-12v1, belonging to the SF scale for the MCS score – which was caused by an error in
the presentation of the copies of the SF-12 that were administered to the participants. Use
of this adapted response scale for the SF-12v1 means that the findings from this study
cannot be reliably compared with those of other studies that have employed the
standardised response scales for this questionnaire.
7.2.3.Paired t-tests vs. MANOVA
Few significant correlations were identified in the descriptive analysis between
variables, and as the sample included less than three subjects per variable, power was
deemed too low to allow the use of a MANOVA. Instead individual paired t-tests were used,
which means that by applying a correction factor to reduce the chances of committing a
Type I error the significance level was more conservative than if a MANOVA were
conducted; this means that it is more likely that meaningful findings can be identified.
7.2.4.Assumption of normal distribution
The subscale of the PNSS measuring psychological need satisfaction for competence in
week 0 did not meet the assumption of a normal distribution; this subscale was however
retained in the analysis as it was the only subscale that did not meet this assumption. The
implication of this deviation from a normal distribution is that the performance of correction
methods is poorer when assumptions for a normal distribution are violated. However, the
use of a correction method can also reduce statistical power, and therefore reduce the
likelihood of obtaining significant findings. Considering that only one significant finding was
obtained and the change in psychological need satisfaction for competence became nonsignificant when the correction method was used, while all other results remained the same,
Bonferroni correction method was still applied in the analysis.
63
7.2.5.Sample size
As the ratio of cases per variable was not high enough to maintain an acceptable level
of degrees of freedom (i.e.: ratio greater than 3 cases for each dependent variable) there
was a reduced likelihood of meeting the assumption of homogeneity of variance required to
perform a MANOVA (Vincent, 2005). If the number of participants had been greater, i.e.:
over 15 producing 3 participants per dependent variable, greater statistical power could
have been achieved, and a MANOVA may have been appropriate in the data analysis.
7.2.6.Language
It may be necessary to design an individual set of measurement tools for these
variables that is tailored to meet the needs of an older adult population, for example, using
more age-appropriate language and items. Anecdotally, during administration of the
questionnaires many of the participants required items to be repeated, rephrased or put
into context to enable them to understand a question before answering it. It is also possible
that the administration of the questionnaire in English may have resulted in translational
error being introduced, as some of the participants in fact spoke Welsh as their first
language, which may have caused some misunderstanding of the meanings of questions.
7.3. Implications
7.3.1.Theoretical
The results from this study show that a targeted strength and balance exercise
intervention may be used to increase satisfaction of the psychological need for relatedness
in community-dwelling, older adults, whilst fulfilling the research recommendations made in
the clinical and public health guidelines (see Research Question 1, Section 4.4). This study
does not provide evidence that such exercise-based interventions result in significant
increases in perceived competence, satisfaction of the psychological needs for competence
and autonomy, intrinsic regulation of exercise behaviours or health-related quality of life
(mental or physical), or significant reductions in fear of falling, and extrinsic and amotivated
regulation of exercise behaviours (see Research Questions 1-2, Section 4.4). In accordance
with the recommendations made for research in NICE guideline 21 (2004), by investigating
changes in psychological measures from SDT and CET perspectives alongside other
psychological measures associated with an increased falls risk (i.e.: greater FOF and lower
HRQoL), this study will contribute towards literature investigating whether patients can be
64
stratified by falls risk, with an end goal of being able to identify who will most benefit from
multi-factorial assessment and intervention during the referral process.
By investigating the effect on psychological measures associated with falls risk (i.e.:
HRQoL and FOF) this study has also been able to evaluate the effectiveness of an exercise
intervention targeting strength and balance and whether or not it has fulfilled public health
guidelines (see Research Question 3, Section 4.4). While the findings from the data show
that there are no significant positive changes in these psychological measures, including
positive changes in behavioural regulation, these non-significant findings may be
attributable to other extraneous variables, including the reduced likelihood of normal
distribution of data in clinical samples (Vickers, 2007).
While not all findings were significant and therefore cannot support all hypotheses, the
non-significant changes observed in all but one variable were in the predicted directions.
This cannot be considered to be meaningful change but it is possible that due to the
limitations in sample size, and therefore limited statistical power, if the study was to be
conducted with a larger sample group there may be a greater likelihood of obtaining
significant findings in subscales as hypothesised over time (see Research Question 4, Section
4.4).
7.3.2.Clinical
This study has shown that this specific intervention does not increase intrinsic
behavioural regulation, need satisfaction for competence, HRQoL or PCS, or reduce FOF or
extrinsic and amotivated behavioural regulation. Based on the findings of this study alone, it
could be suggested that such an intervention targeting strength and balance exercise in
community-dwelling, older adults is not effective in changing such variables. It may also be
interpreted to mean that assessment of these measures (i.e.: motivation from SDT and CET
perspectives) is not an appropriate method of indicating suitability of such an intervention
for individual patients in a clinical context, or evaluation of treatment. However, by
conducting further research and addressing the limitations of this study, including sample
size and language barriers, as well as statistical limitations concerning meeting assumptions
for analysis and reliability of measures, it is possible that more appropriate measurement
tools for these variables can be developed to suit the requirements of those who complete
them, while also enabling valid and reliable measurement of psychological variables in
clinical and research settings. This would mean that provision of multi-factorial interventions
could be individualised by assessment using measurement of motivation from SDT and CET
65
perspectives, as well as enabling evaluation of services that target changes in the
behavioural regulation of exercise.
7.3.3.Future research
While the theoretical implications of the findings may indicate that there is little
change reported in the psychological variables measured, it is possible that these findings
may simply indicate that more evidence is needed to support the use of psychological
measures for need satisfaction, self-determined regulation, quality of life, and fear of falling
in an older adult population, particularly in fallers. Development of an age-appropriate tool
may be more tenable than applying existing questionnaires as used in this study (i.e.: BREQ2 and PNSS), for example, the incorporation of more age-appropriate language and items
could make a difference to the reliability and validity of the results, which is particularly
important when considering the effect of using a clinical sample on normal distribution
alone, let alone older clinical samples. Of course, administration of the questionnaire in the
first language of the participant is ideal, as this would reduce the likelihood of translational
error being introduced to the results. A Wales-centred issue in administration of
psychological questionnaires that are formatted for international use is that Welsh is not
always recognised or prioritised when questionnaires are translated. As English is commonly
spoken in Wales by native Welsh-speaking Welsh citizens and validated versions of
psychological questionnaires translated into Welsh are rare, it is often the case that English
questionnaires are administered, and therefore potential for translational error is
introduced.
Future research studies in this area will also need to ensure larger samples are used
in order to achieve a greater case to variable ratio and therefore greater statistical power.
This in turn may increase suitability for other types of analysis to be used on the data,
including MANOVA, providing a more in depth analysis of the relationships between
variables.
66
Chapter 8: CONCLUSION
The purpose of this chapter is to reintroduce the research aims and objectives of the study.
It will then summarise the key findings from the study and their implications from clinical and
theoretical perspectives.
8.1. Aims and Objectives
Falls are a major cause of injury in older adults in the UK imposing substantial financial
burdens on the health services in the UK (Scuffham et al., 2003). Falls affect many different
factors of physical and mental well-being in older adults and this is reflected in the variety of
research areas concerning falls (Cumming et al., 2000; Lord et al., 1994; Maki et al., 1991; Maki,
1997; Yardley et al., 2005). There are many known risk factors for falling (WHO Europe, 2007)
and efficient and cost effective methodologies for screening and reducing falls risk in older
adults are sought to manage the ageing population in the UK (Scuffham et al., 2003). MultiFactorial Falls Risk Assessments (MFFRA) and Interventions (MFFRI) are used in falls clinics,
among other clinical settings, to identify and reduce falls risk in older adults (Tinetti et al., 1994).
MFFRA may include a general health examination, review of falls history and medications, home
hazard and vision assessments and measures of strength and balance, while MFFRI provide the
appropriate corresponding interventions (Tinetti et al., 1994). However, as such there are no
known measures to assess individual suitability for referral onto specific interventions, i.e.:
exercise-based interventions, based on predictions made using assessment of psychological
variables.
The purpose of this study was to investigate the effects of a targeted strength and balance
exercise intervention on measures of FOF, need satisfaction, behavioural regulation of exercise,
HRQoL and perceived competence in older adults at risk of falling. The proposed implications of
this study included identification of psychological measures associated with changes in
regulation of exercise-related behaviours for use in the development of referral methods
employed in falls prevention programmes. For example, discrimination of patients who are more
or less likely to respond positively to exercise-based fall prevention interventions based on
psychological profile.
8.2. Key Research Findings
The results from this study showed that in a sample of fourteen older adults aged 68 – 89
years, participating in a six week exercise intervention targeting strength and balance the only
67
significant and positive change over the duration of the intervention was in satisfaction of the
psychological need for relatedness. This is also the only finding to agree with the proposed
changes based on CET – that an autonomy supportive environment that nurtures intrinsic
behavioural regulation and perceived competence must satisfy the psychological needs of the
individual.
The absence of significant findings may be due to several limitations of the study, including
poor reliability and exclusion of some subscales, as well as non-normal distribution of data in
some subscales. There was also only a small sample size, which restricted the power of the data,
and therefore the types of analyses that could be conducted were also restricted. The nonsignificant reduction in satisfaction of the psychological need for competence may be caused by
exposure of the participants to challenging environments that they may otherwise avoid. This
increased awareness of their weaknesses may cause the participants in the study to feel less
satisfied in their need for competence by their exercise environment. However, these findings
were not accompanied by any significant change in perceived competence, so this proposed
cause cannot be fully supported with evidence from this study.
One of the key considerations that is very specific to the Mid-Wales region in which the
study was conducted is that the questionnaires were only administered in English, and it is
suggested that in conjunction with the effect of perhaps some ‘age-unfriendly’ terminology used
in these questionnaires, the lack of availability of validated Welsh translated questionnaires may
have caused some misunderstanding of question items, and therefore introducing error in the
data.
8.3. Implications
The implications of the findings from this study include that a targeted strength and balance
exercise intervention may be used to increase satisfaction of the psychological need for
relatedness in community-dwelling, healthy older adults, whilst fulfilling the research
recommendations made in the clinical and public health guidelines. While there is no evidence
from this study that such an intervention can also improve measures of FOF, perceived
competence, behavioural regulation and HRQoL this is more likely to be attributed to issues
arising from the study design and the tools used to measure these changes than the
intervention.
Future research into changes in psychological variables, including motivation from an SDT
perspective in older adult populations, must take into account the influence of language, in
particular regional and age-appropriate alterations to the questionnaires must be considered in
68
administration. Further research must be conducted using the same measurement tools, but in a
larger clinical sample to establish reliability of the tools in these populations. Should these tools
still remain unreliable in large samples, it is recommended that new tools that are ageappropriate are developed through further research to address the research questions in this
research study.
8.4. Summary
While it has not been possible to identify significant findings, this study has identified that
the tools used, such as the BREQ-2 and PNSS, are not necessarily the most appropriate methods
of measuring and evaluating psychological variables in older adults, particularly in a small clinical
sample. However, it has highlighted some areas where improvements may be made in the
design of studies measuring variables using these tools, and provided a platform for discussion
of the application of SDT in an exercise setting that has not yet otherwise been investigated. It is
hoped that the findings from this study will lead to further research into the use of SDT and CET
in the stratification of falls patients as a means of identifying the most individually appropriate
approach when referring patients into falls risk interventions – in particular exercise-based
interventions.
69
SELF-REFLECTION
This chapter offers insight into the thoughts and learning processes of the author as a
researcher, as well as describing the research journey and reflections of the researcher on the
research experience as a whole.
My involvement in the Falls Research Project at Aberystwyth University began a little under
a year after graduating from the university with a BSc in Sport and Exercise Science. At the time I had
been working for almost a year as a learner support advisor in a further education college in
Birmingham whilst studying part time for my Certificate in Sports Massage Therapy. I had been
invited to study for a PGCE whilst teaching on the vocational sport-related courses in this college,
with the intention to continue onto studying for a Masters in Sports Therapy once I had saved
enough money to cover the fees. I had always envisaged that at some point in my career I would
return to university to study as a postgraduate as I had enjoyed the research process of my
undergraduate dissertation so much. I had been highly motivated and interested in my dissertation
project, which involved strength testing and applying biomechanical principles to vertical jump
performance in a young sample undertaking a stretch training intervention. Dedication to my data
collection processes and enthusiasm for my work paid off when my dissertation project was
published in the Journal of Strength and Conditioning Research in 2009, and my undergraduate
supervisor, Samantha Winter – now one of my M.Phil. and Ph.D. supervisors – contacted me to ask
whether I would like to become involved in research into falls as a postgraduate student.
It had been over one year since my only living grandparent, my grandmother, had fallen in
her home. Fortunately, there were no broken bones, or other serious injuries, but the outcome was
that she was moved into a permanent care facility to ensure her safety. She was 92 years old at this
point, and had been blessed with a long and independent life, maintaining social contact with old
friends and regular visits to local family, all the while continuing to care for herself on a day to day
basis without much need for assistance. However, in the months leading up to her fall it had been
clear that signs of dementia were fast setting in, and her need for support had grown to the point
whereby she could no longer live on her own. It was an honour when the opportunity arose for me
to actively contribute towards increasing the longevity of independence in the lives of other older
adults. Over the course of the two years that I have studied for my M.Phil., alongside collection of
data for my Ph.D. I have learnt so much about the importance of maintaining this independence, and
just how fortunate my grandmother, Ruby, had been to enjoy this freedom and security. Of course,
she also had the support of a network of friends, and family. However, there are many older adults
who, for one reason or another, are not so fortunate in this way. Throughout the course of my data
70
collection, my interactions with the participants in the study revealed they had such varying
backgrounds. Some had lived in rural Mid-Wales all their lives, and had established support
networks, others had retired to the area, and their offspring had followed to take care of them in
their later years, but what surprised me most was the number of participants who had no family in
the locality to provide regular contact, support and comfort. I was saddened by this. However, it was
also a major motivational influence for me. In a time and age where it is common for families to be
physically dispersed across the country and the world, separated by work commitments, as well as
love and loss, it seems that being able to maintain independence in older age is not just a luxury, but
a necessity for many people. Through my involvement in the research project in Aberystwyth, both
in my M.Phil and Ph.D. studies, I have been given the chance to influence the provision of care that
will hopefully enable and facilitate independence and enhance quality of life in later life.
As I approach the end of my three year stint as a postgraduate research student at
Aberystwyth University, I can say that I have learned exponentially about what it means to age. In
equal measure I have also built a unique research skill set. In order for research findings to be
practical they need to be ecologically valid, which means that more often than not, a
multidisciplinary approach is required. I am pleased to find that my skills and knowledge of research
across a range of disciplines, including psychology in clinical settings are in fact in high demand as
the dynamics of scientific research in the field of sport and exercise are changing. Most importantly,
when I started my involvement in this research project I was unsure of the importance of the
psychological measures in the evaluation of services for falls prevention. From my review of the
literature, and by analysing and comparing the findings I have been able to identify with the roles of
the psychological theory and constructs, and how they influence performance in exercise-related
interventions – in particular in older adults.
71