Edited by: Matthew Lee Smith, The University of Georgia, USA
Reviewed by: Heather Honoré Goltz, University of Houston-Downtown, USA
This article was submitted to Public Health Education and Promotion, a section of the journal Frontiers in Public Health.
This is an open-access article distributed under the terms of the Creative Commons Attribution License (CC BY). The use, distribution or reproduction in other forums is permitted, provided the original author(s) or licensor are credited and that the original publication in this journal is cited, in accordance with accepted academic practice. No use, distribution or reproduction is permitted which does not comply with these terms.
Stepping On is a small-group, self-efficacy based, 7-week community workshop designed to reduce falls. It addresses four major areas: strength and balance exercises, medication review, home modification, and vision. Sessions are facilitated by a trained leader and a peer co-leader. Physical therapists teach participants to perform and advance balance and strength exercises during three sessions and a pharmacist, low vision expert, and community safety expert attend one session each. A randomized controlled trial, published in 2004, showed Stepping On participants had a 31% reduction in falls compared to controls (
We brought Stepping On to Wisconsin from Australia in 2006, initially training nine leaders from eight counties. Training was informal; leaders read the Australian Stepping On manual and conversed with program developer, Dr. Clemson. In the original study, occupational therapists led the workshop. However, we did not require leaders to be health care professionals. Our initial results were mixed. While leaders, host organizations, and participants loved the program and it spread quickly, evaluation of 151 participants showed no reduction in falls from 6 months before the workshop to 6 months after. Was the program not suitable for community settings in the US, or did it need more development to improve fidelity of implementation?
The CDC provided 4 years of funding to develop and test a Stepping On package for US national dissemination to answer that question. Following the replicating effective programs framework (
Using root cause analysis, we identified underlying causes of the fidelity lapses and mapped solutions. First, we identified three prerequisites for being trained as a Stepping On leader: (1) background as a health professional, allied health professional, or fitness expert; (2) experience facilitating an adult self-management program; and (3) professional experience working with older adults. Second, we better defined the target population for the program. Individuals who use a standard walker for indoor ambulation may be too frail to benefit from Stepping On, and may require a more individualized approach. In addition, older adults with impaired cognition may not be able to participate fully. Third, we learned that sponsoring organizations need to clearly understand what is involved in implementing Stepping On before committing to its success. With the CDC, we developed an implementation guide (
Once we had refined the program for national dissemination, we needed a structure to house it. We created the Wisconsin Institute for Healthy Aging (WIHA) to foster successful dissemination of evidence-based health promotion programs in Wisconsin, and national dissemination of Stepping On. WIHA now trains Stepping On leaders and master trainers, licenses organizations to deliver the program, and provides technical assistance and updates. Master trainers observe one workshop session for each new leader they have trained, providing coaching after the session to ensure fidelity. Once a leader has successfully delivered two workshops and passed a fidelity check, he/she may become trained as a master trainer.
Stepping On has been implemented in Wisconsin and 19 other states with over 7,000 older adults participating to date. Community-based organizations value the program, and WIHA’s training and coaching results in successful adoption and high-fidelity implementation. Older adults enjoy Stepping On and recruitment is relatively easy. Invited experts, once having participated, want to continue. Since we reconfigured the implementation package based on root cause analysis, the program has been highly effective. Evaluation of 2,018 participants from 2008 to 2011 showed a significant 50% reduction in falls from 6 months before to 6 months after the program.
A number of challenges hamper implementation and sustainability. For example, some organizations struggle to identify leaders and guest experts for the workshop. To overcome barriers to adoption, WIHA piloted a coaching intervention to help organizations implement Stepping On. The intervention, based on a process improvement methodology called NIATx (
Program reach is also a challenge. Implementation is limited among African-American, Hispanic, tribal, and other minority cultures. In response to this need, we are working on an adaptation, “Pisando Fuerte,” for Spanish-speaking seniors. Such adaptations are urgently needed to extend benefits of this evidence-based program. Increased funding will help expand Stepping On’s reach. Title III-D of the Older Americans Act provides minimal funds for the aging network to implement evidence-based health promotion programs. There is no reimbursement (yet) through Medicare or Medicaid, and little investment from insurance or health maintenance organizations. While increasing participant fees would help fund program implementation, it would hinder participation by low-income older adults. We need policy changes that enable all at-risk older Americans to benefit from this effective program.
We have successfully translated Stepping On from research to practice. This translation has been possible only through united efforts of researchers, policy-makers, and community agencies. Such a combination of stakeholders, dubbed the “triangle that moves the mountain” (
Dr. Jane E. Mahoney is a Co-Author of Stepping On: building confidence and reducing falls in older adults. Leader Manual, 3rd North American Edition, Freiberg Press, Cedar Falls, IA, USA.
The author gratefully acknowledges Betsy Abramson, Valeree Lecey, and Lindy Clemson, for their helpful suggestions.