A social ecological model of adherence to hip protectors in long-term care

Hip fractures among older adults living in long-term care (LTC) are debilitating and costly, and are nearly always caused by falls. If worn at the time of falling, specific types of hip protectors reduce fracture risk by 80%. However, the clinical value of hip protectors is compromised by poor user adherence in the wearing of these devices. My thesis provides insight into the factors governing adherence with hip protectors in LTC. In my first study, I conducted a systematic review of extant literature. A total of 1086 articles were identified, and of these, 28 met our inclusion criteria. Barriers and facilitators were grouped into four taxonomies: (i) system-related; (ii) caregiver-related; (iii) resident-related; (iv) hip protector-related. My second study involved the development and validation of the C-HiP index to measure commitment to hip protectors amongst paid care providers in LTC. Exploratory factor analysis yielded a factor structure consisting of two lower-order factors and a single higher-order factor. Expert evaluation by LTC clinicians provided evidence of content validity. Internal consistency was high (Cronbach’s alpha=0.96). My third study identified social ecological determinants of commitment to hip protectors by means of a cross-sectional survey (n=529). Mean (SD) commitment was 4.15 (0.71) out of 5.00. Commitment was associated with race/ethnicity, occupation, organizational tenure, awareness of a padded hip fracture, familiarity of hip protectors, perceptions of transformational leadership, communication, resident-provider relationship quality, and the existence of a champion of hip protectors within the home. Finally, I conducted a 12-month retrospective cohort study in fourteen publically subsidized LTC homes to identify factors governing adherence with hip protectors, and to examine the clinical value of hip protectors to prevent hip fractures. The percentage of residents who wore hip protectors during at least one fall was negatively correlated with regional socioeconomic deprivation (ρ=-0.630) and the percentage of residents with depression (ρ=-0.538), and was positively correlated with the percentage of residents paying for care privately (ρ=0.539) and who fractured their hip in the past 180 days (ρ=0.677). The relative risk of hip fracture was 0.36 (95% CI 0.14–0.90) in falls with hip protectors compared to falls without hip protectors.