Pharmacy fall prevention services for the community‐dwelling elderly: Patient engagement and expectations

Abstract Medication use is an important risk factor for falls. Community pharmacists should therefore organise fall prevention care; however, little is known about patients' expectations of such services. This qualitative study aims to explore the expectations of community‐dwelling older patients regarding fall prevention services provided by community pharmacies. Telephone intakes, followed by three focus groups, were conducted with 17 patients, who were aged ≥75 years, used at least one fall risk‐increasing drug (FRID) and were registered at a community pharmacy in Amsterdam, the Netherlands. Some time of the focus groups was spent on playing a game involving knowledge questions and activities to stimulate discussion of topics related to falling. Data were collected between January 2020 and April 2020, and all focus groups were audiotaped and transcribed verbatim. The precaution adoption process model (PAPM) was applied during data analysis. Patients who had already experienced a fall more often mentioned that they took precautions to prevent falling. In general, patients were unaware that their medication use could increase their fall risk. Therefore, they did not expect pharmacists to play a role in fall prevention. However, many patients were interested in deprescribing. Patients also wanted to be informed about which medication could increase fall risk. In conclusion, although patients initially did not see a role for pharmacists in fall prevention, their perception changed when they were informed about the potential fall risk‐increasing effects of some medications. Patients expected pharmacists to focus on drug‐related interventions to reduce fall risk, such as deprescribing.


| INTRODUC TI ON
One-third of people aged 65 years and older fall at least once each year (Morrison et al., 2013). Given the potentially serious consequences of falls, including physical injury and increased use of health services, the prevention of falls is of utmost importance (Stel et al., 2004). Furthermore, people who experience a fall incident often develop a fear of falling, which leads to limitations in daily activities with social withdrawal, functional decline and reduced mobility. A fear of falling also increases fall risk (Liu, 2015).
Falling is a multifactorial problem, and medication use is an important, potentially modifiable risk factor (Fonad et al., 2015;Huang et al., 2012). Since one of the core tasks of community pharmacists is to ensure safe medication use and prevent medication-related problems, they should play a prominent role in reviewing the use of fall riskincreasing drugs (FRIDs) (Cooper & Burfield, 2009;Walsh et al., 2019).
Apart from this, pharmacists can provide information on other modifiable risk factors, such as exercise, diet and a safe home environment.
Prevention programmes should align with patients' preferences to ensure patient engagement. Therefore, the expectations of patients must be taken into account during the development of interventions (Baris & Seren Intepeler, 2019;McMahon et al., 2011). Fall prevention programmes previously failed because of a mismatch between the views of healthcare providers and those of their patients regarding fall risk assessment. Patients did not accept their individual fall risk assessment by nurses (Radecki et al., 2018). Moreover, patients had diverse reasons for not wanting to participate in an exercise-based fall prevention programme delivered by community care staff (e.g. patients being too busy, already doing exercise, being too old, experiencing a fear of new things or falling and disliking exercise) (Burton et al., 2020). Most importantly, since patients often underestimate their own fall risk, they are not motivated to enrol in fall prevention programmes (Bowling & Ebrahim, 2001;Chen et al., 2016). Furthermore, patients' autonomy must be maintained during such programmes to keep them engaged (McMahon et al., 2011).
Patients' needs and expectations regarding fall prevention programmes delivered by community pharmacies have not been studied before. More knowledge is needed on how patients would like pharmacists to approach them for fall prevention interventions and what the intervention programmes should look like. In this qualitative study, we investigated the engagement of community-dwelling older people in fall prevention, focusing on fall prevention services conducted by community pharmacies.

| Study setting and population
A qualitative study was conducted consisting of short individual telephone intakes followed by focus group discussions. One researcher (MG) selected patients from the pharmacy information system of a community pharmacy in Amsterdam, and another researcher (OJ) invited them to participate in the focus groups.
The following inclusion criteria were used for selection of patients: • Age ≥75 years; • Simultaneous use of at least five drugs, with at least one being a FRID (either cardiovascular or psychotropic) de Vries et al., 2018); • Community-dwelling; • Physically and mentally able to attend the focus group in the community health centre; • Proficient in Dutch.
Patients were invited by telephone, and after verbal consent, a telephone intake followed. They were briefly asked about their fall experiences and interest in fall prevention (see below). Thereafter, an information letter and consent form were sent by postal mail to their addresses. All participants provided written informed consent before the start of the focus group discussions. All data were collected between January 2020 and April 2020.
The study was approved by the institutional review board of the Division of Pharmacoepidemiology and Clinical Pharmacology, the Department of Pharmaceutical Sciences, Utrecht University. Results were reported according to the consolidated criteria for reporting qualitative research (COREQ) guidelines (Supporting Information, Appendix S1) (Tong et al., 2007).

What is known about this topic?
• Medication use is an important risk factor for falls.
• Community pharmacists can contribute to fall prevention through the identification and modification of fall risk-increasing drug (FRID) use in older people.
• Prevention programmes should match with patients' preferences to ensure patient engagement.

What this paper adds?
• For older people, the experience of a fall would be the most important reason to engage in pharmacist-led fall prevention services.
• Most older patients were unaware of the fall riskincreasing effects of medication. Therefore, they lacked expectations about pharmacy fall prevention services.
• Older patients' interest in pharmacy fall prevention services related primarily to the deprescribing and provision of information about FRIDs.

| Telephone intakes
Semi-structured telephone intakes of approximately 30 min were performed with participants prior to conducting the focus groups.
These intakes aimed to obtain individual fall-related background information, such as previous fall experiences, applied precautions to reduce fall risk and interest in pharmacy fall prevention services. The researcher (OJ) used a topic list (Table 1) for the telephone intakes and completed a structured form immediately after each intake.

| Focus groups
Participants were divided into three focus groups, resulting in five to seven participants per session. The duration of each session was 1.5-2 hr. The first focus group was chaired by an experienced pharmacy practice researcher (EK), while two another researchers (MG and OJ) were second listeners, who occasionally stimulated group discussion and took field notes. The second and third focus groups were chaired by OJ, while MG was the second listener during these focus groups and EK took field notes during the second focus group. All focus TA B L E 1 The topic list used in the telephone intakes and the topics and statements addressed during the focus groups Abbreviation: PAM, precaution adoption process model. groups were audiotaped and transcribed verbatim afterwards, and all patients received a short report with the main findings of the focus groups. Data saturation was discussed after the third focus group.
A topic list was made to guide the focus groups (Table 1). First, the findings from the telephone intakes were briefly discussed in the focus groups. Thereafter, additional topics derived from findings of the intakes, the first focus group session and the literature ( Table 2), were addressed in those groups.
The group discussion was followed by a game of DobbelFit

| Data analysis
All audio recordings of the focus groups were transcribed verbatim. The intake forms and focus group transcripts were imported into NVivo Version 12 software, and participants' names were replaced by a study code to ensure their anonymity. The transcripts were coded independently by two researchers (OJ and MG), and discrepancies in coding were discussed with EK until consensus was reached. Deductive coding was used-the codes were based on the topic list. A number of additional codes were identified during transcription (inductive coding).

| Interpretation of the data
The precaution adoption process model (PAPM) was used in the data analysis (Weinstein & Sandman, 1992). This model has often been used to describe patients' decision-making processes in a wide range of situations, including HPV vaccination (Barnard et al., 2017;Shapiro et al., 2018), treatment for osteoporosis (Adami et al., 2020) and the screening of diverse cancers (Ferrer et al., 2011;Marlow et al., 2017).
The PAPM consists of seven stages, representing all stages of taking precautions to reduce risk, and it was considered as the most appropriate model to assess fall preventive health behaviour. In contrast to other health behaviour theories and models, the PAPM includes the stage at which patients are not yet aware of a threat or a risk. In the case of fall prevention, this applies to patients who are not afraid of falling and therefore have not (yet) taken precautions. The PAPM also investigates behavioural changes and patients' reasons for engaging.

| Background characteristics
In total, 218 patients aged 75 years or older using five chronic medications were identified from the pharmacy information system. Of these, 35 patients were purposely selected by the researcher/pharmacist (MG) and invited to participate. The reason for this selection was that they were known to visit/contact the pharmacy regularly and were thus able to independently attend the focus group session in the community health centre. Twenty participants agreed to participate, but just before start of the focus groups, three of them cancelled. Therefore, 17 participants attended the focus groups ( Figure 1). The reasons for cancellation were having other appointments and not feeling well enough. All participants met the inclusion criteria, except for one woman of 69 years. Her husband, who met the inclusion criteria, was originally invited, but she participated instead of him. This woman's views were comparable with the overall findings, and she had experienced multiple falls.
Slightly more women (52.9%) than men participated, and the mean age of the participants was 82.1 years (standard deviation [sd] = 4.9 years). Most participants (58.8%) reported at least one fall incident ( Table 3). During the third focus group, no new topics were addressed, and the research team concluded that data saturation was achieved.

| The PAPM
The PAPM consists of seven stages of patients' decision-making to act on fall prevention. Stage 1 (unawareness) and Stage 2 (nonengagement) of the model were combined in the analyses, as both describe stages in which patients are not taking precautions to prevent a fall. Stage 3 (undecided about acting) refers to the decision-making between acting and non-acting on fall prevention, and Stage 4 (decided not to act) represents non-acting behaviour.
Stage 5 (decided to act), Stage 6 (acting) and Stage 7 (maintenance) describe acting behaviour and were also combined during analyses. Furthermore, the PAPM stage transitions were identified and analysed.
Participants were in different stages of the PAPM ( Figure 2).
Furthermore, they were sometimes found in one PAPM stage for certain behaviours, but in different stages for other behaviours.

Stages 1 and 2).
Patients' perceived fall risk seemed to influence their engagement in fall prevention activities; specifically, a low perceived fall risk was often co-reported with a low interest in fall prevention. Four patients perceived no risk of falling and were consequently not interested in participating in fall prevention programmes. Those who were not interested in fall prevention services also indicated that they were not taking precautions to reduce fall risk. They stated that they were healthy, exercised and/or walked a lot. Although exercising could be seen as a precaution to prevent falls, these patients explicitly mentioned that they were not taking precautions to prevent falls. One patient who perceived no risk even expected that healthcare providers would agree that he was not at risk: When the blood pressure decreases, this is possible.
That's my gut feeling; I am not an expert.

Topic Scientific foundation
Fall experiences Acceptance of fall risk impairs the personal identities of older patients (Gardiner et al., 2017). However, by experiencing a fall, personal fall risk may be acknowledged (McInnes et al., 2011). Therefore, previous fall experiences trigger behavioural changes and engage patients in fall prevention activities (Robson et al., 2018) Precautions The importance of being careful is often recognised by older people. They avoid certain activities, and precautions are taken, even by patients who deny experiencing a fear of falling (Gardiner et al., 2017). Exploration of the precautions taken provides information about the established engagement in fall prevention Interest in fall prevention service Patients have reported that the necessity of fall prevention activities is associated with ageing. It may be disturbing for older patients to belong to the group who is in need of these activities (McInnes et al., 2011). Their interest in a fall prevention service indicates whether they are already engaged Needs and wants regarding fall prevention service Older people may experience asking for help in fall prevention as a loss of their independence. However, a fall can seriously impair their independence (Gardiner et al., 2017). When patients recognise that prevention services could also protect their independence, this could enhance their engagement Expectations from pharmacists Patients often do not know who should be approached for support in fall prevention (Robson et al., 2018). When they are unaware that their pharmacist could be consulted, it is unlikely that they will ask for the pharmacist's assistance. Therefore, higher established expectations from pharmacists could be related to enhanced patient engagement Deprescribing Deprescribing aids in the prevention of adverse drug reactions, including increased fall risk. It has been reported that patients sometimes think their medication might no longer be necessary for the treatment of their disease(s) (Reeve et al., 2013b;Reeve, Wiese, Hendrix, et al., 2013). Therefore, many may be interested in deprescribing and would like to know more about its advantages and disadvantages. Pharmacists can facilitate the deprescribing process, for example, by conducting medication reviews Information about fall prevention/drugs For behavioural changes, the understanding of fall risk is essential. Patients are often unaware of potentially modifiable risk factors (Robson et al., 2018

| Undecided about acting (PAPM Stage 3)
Patients in this stage were undecided about acting on fall prevention.
Informing them about fall risks seemed to aid in the decision-making process. Patients would like to receive more attention and appreci-

| Decided not to act (PAPM Stage 4)
Although many patients considered that part of their medication was superfluous, not all patients were interested in deprescribing.
They either believed that in the absences of drug complaints, withdrawal efforts were unnecessary or believed their medications were essential to treat their disease (

| Acting (PAPM Stages 5, 6, and 7)
Engagement with fall prevention was particularly evident in patients who were already taking precautions. For patients who had expe- On the other hand, several patients perceived being at low risk of falling because of their daily exercises. All patients emphasised that daily exercises were important for their overall health status and for maintaining their fitness. Therefore, daily exercise alone could also be seen as some form of engagement with fall prevention: When the pharmacy tells me I lose balance due to medication, then I would ask for an alternative.

| D ISCUSS I ON
Patients are at different stages of engagement in in fall prevention activities, ranging from being unaware of fall risks to being highly active in the prevention of falls. Therefore, they have different needs and expectations. In particular, patients who had previously experienced a fall were more inclined to prevent future falls and displayed interest in pharmacy fall prevention services.

F I G U R E 2
The application of the precaution adoption process (PAPM) model on possible thoughts or beliefs of patients during their decision-making in fall prevention Our findings confirm previous results demonstrating that older patients often underestimate their fall risk and are therefore not engaged in fall prevention activities (Bowling & Ebrahim, 2001;Chen et al., 2016;Yardley et al., 2006). Furthermore, it has been reported that patients who have experienced a previous fall are more inclined to acknowledge their fall risk (McMahon et al., 2011).
Regardless of the stage of engagement, patients were unaware of the existence of FRIDs. Fall risk as an adverse effect of medication was often not acknowledged by patients, and it seemed to impact the level of engagement in a pharmacy fall prevention service. In the literature, patients' belief that their medication is necessary and beneficial is an important barrier for deprescribing (Reeve et al., ,2013(Reeve et al., , , 2013a. In our study, a few patients also mentioned the necessity of medication, and this was served as an argument to not be engaged in a medication review focused on reducing fall risk. Patients wished to be informed by the pharmacist about how their medication use may increase their fall risk (e.g. at the first dispensing of a new drug). They also expected patient information leaflets to contain this information. Our findings correspond with earlier findings that patients are positive about being educated about their safety. Despite this, informing patients might not always be sufficient for actual behavioural changes (Schwappach, 2010).
From the patient perspective, pharmacists' fall prevention interventions should focus on deprescribing and providing information about how medication may enhance fall risk. Informing patients could facilitate engagement when they are in PAPM Stage 1 or 2 (unawareness/non-engagement) and support their decision-making when they are in PAPM Stage 3. Many patients in our study were also interested in targeted interventions, which suggests that these patients were already in PAPM Stage 5 (decided to act). Specifically, these patients indicated being interested in deprescribing. They may be concerned about the high number of drugs, wondering whether all drugs were still necessary. Additionally, it has been shown that patients' drug knowledge is often poor, but crucial for involvement in decision-making (Modig et al., 2012). Deprescribing interventions presumably will be more successful when patients have increased drug risk awareness. Earlier findings suggest that when patients are not experiencing side effects and are not concerned about future harm, they may not see the benefit of drug withdrawal (Reeve et al., 2016). However, a previous study also found that over 90% of older patients would like to try medication withdrawal, as long as the prescriber agrees (Reeve, Wiese, Hendrix, et al., 2013). This corresponds to our findings: Although not all patients were engaged in fall prevention in general, many still showed interest in deprescribing.
Patients who had experienced a fall tended to acknowledge their fall risk more often and were consequently more frequently found in PAPM Stage 5, 6 or 7 than the others. As a side note, PAPM stages were not consistent for all aspects of fall prevention activities, as individual patients were sometimes found in different PAPM stages for different fall prevention activities. Overall, these patients were consciously adapting precautions, including reducing home environmental hazards, avoiding outdoor activities (walking, cycling) and quality of life, increased risk of falling and institutionalisation (Liu, 2015). Thus, the adapted precautions because of fall anxiety may not always be beneficial for fall prevention. On the plus side, a fear of falling indicates patients are more or less engaged and hence should at least be found in PAPM Stage 3.
Patients were sceptical about whether pharmacists could organise fall prevention, mentioning that pharmacists and other healthcare providers do not have enough time to do so. Furthermore, because of limited time, they expected pharmacists to focus primarily on medication safety. Despite this, patients reported that they would like to receive more attention from their health care providers.

| Strengths and limitations
An important strength of this study was the combination of the telephone intakes and focus group which provided comprehensive data.
The telephone intakes ensured that the perspectives of all patients, particularly those who were more reluctant to speaking in groups, were investigated. Data from the intakes were used as input for the set-up of the focus groups. In these groups, patients were encouraged to respond to discussions or complement one another's opinions. In particular, the use of the DobbelFit game during the focus groups was innovative, contributed to a relaxed atmosphere and was appreciated by the participants. The PAPM supported the data analyses, as it helped to identify the stages and engagement triggers of patients. Despite the PAPM being applied retrospectively, during data analysis, the model fitted the data well and enhanced interpretability.
The major limitation of this study was the generalisability of findings. First, all participants were from one single pharmacy in the suburb area of Amsterdam. However, the organisation of healthcare may differ in a strongly urbanised environment compared with small villages. It is challenging for healthcare providers to establish strong relationships with patients in the larger healthcare centres of cities. Therefore, satisfaction about healthcare is generally higher in rural populations (Batbaatar et al., 2017). of falling, and subsequent engagement in fall prevention, was also found in patients without fall experiences (Scheffer et al., 2008).
Furthermore, another subgroup has also been identified in studies, but not in our work. This group covers patients with many fall experiences but who consider themselves to be 'non-fallers' and who neither experience fall anxiety nor are engaged in fall prevention (Gardiner et al., 2017). With the exception of those viewpoints, our findings correspond to earlier findings from other studies, which strengthens the idea the perspectives are applicable to most patients.

| Implications
Pharmacists should spend more time on fall prevention (e.g. screen- ing for patients at risk and informing them about fall prevention). providers, which is a recommended approach for successful fall prevention (Kobayashi et al., 2017).
Pharmacy fall prevention care should specifically be provided to patients using FRIDs and those who have reduced mobility (e.g. patients who are using a walking aid or standardly request their medication to be home-delivered). Pharmacists could consider organising educational group sessions about fall prevention for these patients.
In these sessions, evidence-based effective interventions should be addressed, including the deprescribing of FRIDs (Blalock et al., 2010;van der Velde et al., 2007), the relevance of exercising and home environmental recommendations (Gillespie et al., 2012).
In addition to informing patients orally or in group sessions, providing written information should be adequate as well. Patients most often preferred to read or search for information about falls and drugs themselves rather than consulting their healthcare provider.
A previous study revealed that patients were passive in consulting their caregiver, because they thought their health professionals would inform them if there was a problem. In contrast, caregivers often mentioned being reactive in providing information (Lee et al., 2013). Encouragement from health practitioners is important for patients to participate in fall prevention activities (Yardley et al., 2006). Therefore, the information provided in patient information leaflets should be complete, with a section on fall-related side effects. Future research should investigate whether educating patients on the relationship between medication and fall risk increases their engagement in fall prevention services offered by pharmacists.

| CON CLUS ION
Although patients were initially doubtful about the role of pharmacists in fall prevention, this changed when they were informed about the potential fall risk-increasing effects of some medications. Interest came mainly from patients who had experienced a fall. Furthermore, patients expected pharmacists to focus on drug-related interventions to reduce fall risk, such as deprescribing.
Finally, patients wanted to be well informed, both orally and in writing, about FRID effects.

ACK N OWLED G EM ENTS
We want to thank all participants for sharing their valuable insights.
In addition, we would like to thank the Plesman Apotheek, and in particular A.U. Beijnen-Bandhoe PharmD, for making this research possible.

CO N FLI C T S O F I NTE R E S T
There were no conflicts of interest.

DATA AVA I L A B I L I T Y S TAT E M E N T
Author elects to not share data due to privacy/ethical restrictions.