Skip to main content

Evaluating an in-home multicomponent cognitive behavioural programme to manage concerns about falls and associated activity avoidance in frail community-dwelling older people: Design of a randomised control trial [NCT01358032]



Concerns about falls are frequently reported by older people. These concerns can have serious consequences such as an increased risk of falls and the subsequent avoidance of activities. Previous studies have shown the effectiveness of a multicomponent group programme to reduce concerns about falls. However, owing to health problems older people may not be able to attend a group programme. Therefore, we adapted the group approach to an individual in-home programme.


A two-group randomised controlled trial has been developed to evaluate the in-home multicomponent cognitive behavioural programme to manage concerns about falls and associated activity avoidance in frail older people living in the community. Persons were eligible for study if they were 70 years of age or over, perceived their general health as fair or poor, had at least some concerns about falls and associated avoidance of activity. After screening for eligibility in a random sample of older people, eligible persons received a baseline assessment and were subsequently allocated to the intervention or control group. Persons assigned to the intervention group were invited to participate in the programme, while those assigned to the control group received care as usual. The programme consists of seven sessions, comprising three home visits and four telephone contacts. The sessions are aimed at instilling adaptive and realistic views about falls, as well as increasing activity and safe behaviour. An effect evaluation, a process evaluation and an economic evaluation are conducted. Follow-up measurements for the effect evaluation are carried out 5 and 12 months after the baseline measurement. The primary outcomes of the effect evaluation are concerns about falls and avoidance of activity as a result of these concerns. Other outcomes are disability and falls. The process evaluation measures: the population characteristics reached; protocol adherence by facilitators; protocol adherence by participants (engagement in exposure and homework); opinions about the programme of participants and facilitators; perceived benefits and achievements; and experienced barriers. The economic evaluation examines the impact on health-care utilisation, as well as related costs.


A total number of 389 participants is included in the study. Final results are expected in 2012.

Trial registration


Peer Review reports


Falls and concerns related to falls are very common in community-dwelling older people. About one in three older people living in the community experiences at least one fall each year, of which roughly half results in an injury [1, 2]. Interestingly, around two-thirds of older people report concerns related to falls [3], of which roughly half report activity avoidance as a result of these concerns [48]. Concerns about falls can be present in both people who have fallen and people who have not [9]. These concerns have been linked to decreased balance performance, decreased mobility, functional decline, low quality of life, institutionalisation and falls [3, 1013]. Recent research has shown that concerns about falls can lead to falls irrespective of any physiological fall risk [13].

Concerns about falls can be considered as a multifactorial problem [14, 15]. As a consequence, successful programmes should not only target concerns about falls but should also focus on aspects like increasing self-efficacy and a sense of control regarding the risks of falling, setting realistic goals for increasing activity, changing the environment to reduce the fall risk and promoting physical activity to increase strength and balance [1519].

Cognitive behavioural therapy could be seen as a suitable strategy to reduce concerns about falls by modifying patterns of thoughts (cognition) and actions (behaviour) that contribute to the concern.

One of the programmes with proven effectiveness is the Dutch version of 'A Matter of Balance' (AMB-NL) [20]. This multicomponent cognitive behavioural group programme consists of eight weekly group sessions and a booster session after six months. It has shown favourable effects on concerns about falls, perceived control over falling and daily activity, after at least 8 months of follow-up. In addition, significantly fewer recurrent fallers were observed in this group after 14 months of follow-up [15]. Notwithstanding these positive outcomes, approximately 40% of the participants attended less than five sessions out of a total eight, mainly because of health problems [21]. It seems that, in particular, frail older people refrained from attending the group programme. This is also seen in other group programmes that explicitly address concerns about falls, and target frail older people living in the community [18, 22].

The aim of this project is to develop an in-home programme to enable frail older people to participate, as well as people who prefer an in-home approach rather than a group approach [Dorresteijn, Zijlstra, Van Eijs, Vlaeyen, Kempen: Older people's preferences regarding programme formats for managing concerns about falls, submitted]. This paper presents the design of a randomised controlled trial evaluating 'A Matter of Balance at Home' (AMB-Home) in frail older people, living in the community in the Netherlands. The objectives of this trial are to conduct: (1) an effect evaluation to determine the effects of this in-home programme on concerns about falls and fall-related activity avoidance, and additional outcomes including disability and fall incidents; (2) a process evaluation to determine the feasibility of the programme; and (3) an economic evaluation uncovering the impact of the programme on health-care utilisation and related costs.



The study concerns a two-group randomised controlled trial with a baseline measurement and follow-up measurements after 5 (directly after the programme) and 12 months (see Figure 1). The selection of potential participants was performed between March and December 2009 in four consecutive cycles. Each cycle lasted about 15 months and included: screening for eligible participants; baseline measurement; stratified randomisation; the intervention period; and follow-up measurements. The Medical Ethics Committee of the Maastricht University/Academic Hospital Maastricht in The Netherlands approved this trial.

Figure 1

Study design. 1a Displaying effect and economic evaluation. S = screening; B = baseline; FU1 = 5-month follow-up; FU2 = 12-month follow-up. 1b Displaying process evaluation. QCf = questionnaire filled in by facilitator for each participant for each contact, V = voice recording for selection of contacts, Qf = questionnaire filled in by facilitator for each participant, Qp = questionnaire filled in by participant after programme, and If = group interview with facilitators.

Recruitment of participants

Three communities, Maastricht, Sittard-Geleen, and Heerlen, situated in the southeast of The Netherlands have been selected for participation in the trial. The municipal registry offices selected 11,490 addresses of community-dwelling people of 70 years or over in their district, at random. To screen for eligibility, people received a short postal questionnaire with a freepost envelope, as well as information about the trial and an informed consent form. After a fortnight, reminder letters were sent. The questionnaire assessed socio-demographics and fall-related variables and inclusion and exclusion criteria.

Older people were included if they met all of the following criteria: 1) they reported at least some concerns about falls; 2) they reported at least some associated avoidance of activity; 3) they perceived their general health as fair or poor [23]; 4) they lived in the community; 5) they were 70 years of age or older; and 6) they were willing to participate (signed informed consent form). People were excluded if they were confined to bed, were restricted by the permanent use of a wheelchair, were waiting for a nursing home admission, experienced substantial hearing or vision impairments or they failed the shortened version of the Abbreviated Mental Test (AMT4) [24] assesses cognitive impairment and, subsequently, the Telephone Interview Cognitive Status (TICS) [25]. In addition, a restriction was applied to couples; to prevent reciprocal influencing only one partner of a couple was allowed to participate in the trial. Lots were drawn if this selection process was necessary.


Participants were assigned to the programme or the no-treatment control group directly after the baseline measurement using stratified randomisation. This randomisation was performed in blocks of two on the basis of one prognostic factor: the level of concern about falls (some, regular, often, and very often). Computerised alternative allocation was used in the randomisation process, which was performed by an external agency.


Development of the programme

AMB-Home is based on the Dutch version of a cognitive behavioural group programme for older people living in the community named 'A Matter of Balance' (AMB-NL). AMB-NL is a translated, adapted and evaluated version of 'A Matter of Balance' [20], a programme that originated in the USA [18]. In the development process of the home-based version for frail older people, all components and techniques of the group programme were assessed on their appropriateness for the new targeted population, the in-home setting, and future implementation in Dutch health-care. Therefore, experts (n = 8, see Acknowledgements) in the domain of programme development and behavioural change were consulted and a pilot study with six volunteers was conducted to test the programme initial feasibility.

Substantial elements of the AMB-NL programme, such as cognitive restructuring, a DVD for modelling purposes, i.e. presenting stories of other people reporting concerns about falls and their solutions, and the discussions on themes related to fall prevention themes are maintained in AMB-Home. However, several adaptations have been made. First, the programme of AMB-Home consists of seven sessions (three home visits and four telephone contacts) in contrast to the eight sessions and a booster session after six months in AMB-NL. Second, the formulation and review of personal action plans, regarding the themes of the sessions, receive a more prominent role throughout the programme to encourage active participation [21, 26]. Third, the physical exercises performed in AMB-NL are not included in AMB-Home since supervision of the appropriate execution of these exercises is not feasible. Fourth, a new component is added to home visit 3. During this visit, the participant actually practises a specific (fear-related) problem in daily life in the presence of the programme facilitator. Lastly, motivational interviewing is added as a discussion technique, to motivate participants to change their beliefs and behaviour, regarding concerns about falls and activity avoidance. See Table 1 for additional information on the similarities and differences of both programmes.

Table 1 Main Topics of the In-home Multicomponent Cognitive Behavioural Intervention

Contents and format of the programme

The in-home programme aims to teach participants how to deal with their concerns about falls and related avoidance of activity, in order to increase their physical, social and functional activities. AMB-Home consists of seven individual sessions, including three home visits (60, 60 and 75 minutes, respectively) and four telephone contacts (35 minutes each). During each session a main theme is addressed. The themes of the programme are: concerns about falls; thoughts about falling; physical exercise; asserting oneself; overcoming personal barriers; safe behaviour; and managing concerns about falls (see Table 1). All sessions have a similar structure: review the previous session (except the first session); discuss the current session's theme; and formulate a concrete and personal action plan, related to the theme discussed. The contents of each session are described in detail in a facilitator's manual, and participants receive printed materials, including background information on the session's theme and worksheets to complete during or between the sessions.

The principles of cognitive restructuring [27] are used for shifting maladaptive to adaptive attitudes with respect to falling, as well as for increasing self-efficacy beliefs and feelings of control. Four strategies are applied to obtain these goals: (1) restructuring misconceptions to promote a realistic view of fall-risk and making concerns about falls controllable; (2) setting realistic goals for increasing activity and safe behaviour; (3) adapting the environment to reduce the fall-risk; and (4) promoting the uptake of daily life activities that are avoided owing to concerns about falls. The following techniques are applied in the programme. Motivational interviewing is used as a discussion technique to encourage the internal motivation and increase the self-efficacy of participants. This technique is a client-centred approach, with reflective listening and positive affirmations rather than direct questioning, persuasion, or advice-giving [28]. In addition, to tailor the programme to the participant's needs and preferences, participants are encouraged to come up with activities that they consider important and which they would like to perform safely. These activities are then incorporated into programme elements such as action planning. Participants experiencing difficulties in recognising such activities are prompted in this process by being shown them 16 drawings of activities of the Iconographical Falls Efficacy Scale (Icon-FES) [29]. Action plans are used to bridge the gap between behavioural intentions and behaviour itself. In every session a personally relevant activity is chosen by the participant. The 'when', 'where', and 'how' to perform the activity, and ways in which to pursue the activity in the face of obstacles, as well as expected challenges and possible solutions are discussed [30]. The activity is supposed to be carried out by the participant prior to the next session. In session 5, a more challenging daily activity (related to concerns about falls) in daily life is first performed under the direct supervision of the facilitator [31]. Furthermore, a DVD is used for modelling by presenting stories of other people reporting concerns about falls, and moreover, to encourage problem-solving skills of the participant, which is one of the core skills of self-management [32]. At last, the participant is encouraged to invite a significant other. This person (often a spouse or other relative, friend or neighbour) is present at the home visits and shown how to help and give support during the programme. An overview of the programme is shown in Table 1.

The AMB-Home programme was facilitated by eight trained nurses, that were qualified in the field of geriatrics and work for home-care agencies. Facilitators received a two-day training in which the manual was studied. During the training, special attention was given to aspects such as motivational interviewing, behavioural change, and 'exposure in vivo' to feared activities [31], by professionals in these particular fields. The facilitators were responsible for planning the sessions with the participant, according to the given format and time schedule. Throughout the start of the programme, the researchers periodically observed the facilitators during their contacts with participants. Monthly group meetings of the facilitators and the researchers were held to evaluate and discuss the progress of the trial, the flow of participants, the programme and the performance of the programme by the facilitators.


Effect evaluation

Table 2 presents the outcomes of the effect evaluation.

Table 2 Outcome measures of the effect evaluation

Primary outcome measures

The primary outcomes of the effect evaluation are concerns about falls and the avoidance of activity as a result of these concerns. Concerns about falls are assessed by the 16-item Falls Efficacy Scale-International (FES-I). Participants are asked to indicate how concerned they are about falling while carrying out several activities of daily living (1 = not all concerned to 4 = very concerned) [33, 34]. In addition, when people indicate that they are at least somewhat concerned about falling while carrying out an activity, people are asked to indicate to what extent they avoid the activity as a result of their concerns (FES-IAB; AB indicates Avoidance Behaviour; 1 = never to 4 = often).

Secondary outcome measures

Secondary outcomes are disability and the number of falls. Disability is measured by the Groningen Activity Restriction Scale (GARS) [35]. The 18 items of the GARS measure disability in the area of ADL (Activities of Daily Living including mobility) as well as IADL (Instrumental Activities of Daily Living). Participants are asked if they are currently able to perform the activity (1 = yes, fully independently to 4 = no, only with help from others). The number of falls is registered continuously during the course of the trial by a fall calendar. A fall is defined as an event that results in a person coming to rest inadvertently on the ground or on another lower level [36]. If a fall occurs, participants indicate on the calendar: (a) the location of the fall (indoor or outdoor); and (b) the number of times medical attention is received owing to the fall.

Tertiary outcome measures

The tertiary outcomes include: the perceived consequences of falling (CoF) with two 6-item subscales ('loss of functional independence' and 'damage to identity') [9]; catastrophic beliefs about the consequences of a fall (CAFS: Catastrophising About Falling Scale, 5 items) [37]; perceived control over falling (PCOF; 4 items) [38]; mastery (7 items) [39]; feelings of anxiety and symptoms of depression with two 7-item subscales of the Hospital Anxiety and Depression Scale (HADS) [40, 41]; social support interactions (SSL12-I: Social Support List of Interaction, 12 items) [42]; and health-related quality of life (SF-12: Health Survey, 12 items) [43].

Additional variables

Several variables are assessed to provide insight into the population under study, and to interpret the outcomes of the study. The socio-demographic and health-related variables, assessed during the process of screening for eligibility, are: age, gender, living alone or not, educational level, perceived general health (item one of the MOS SF-20) [23, 44], and self-reported impaired vision and hearing [45]. Other health-related variables assessed during the baseline measurement are: chronic medical conditions (a 5-item checklist) [46] and cognitive status (AMT4: shortened version of the Abbreviated Mental Test; 4 items and TICS: Telephone Interview Cognitive Status; 11 items) [24, 25]. Furthermore, 1-item questions on concerns about falls, the avoidance of activities owing to these concerns and the number of falls are assessed at baseline, as well as at all follow-up measurements. Lastly, at the baseline, participants are asked about their outcome expectations with regard to the programme [47].

Process evaluation

To determine the feasibility of the programme and to identify factors that may influence its effectiveness, the following outcomes of the process evaluation are assessed: characteristics of the population reached (reach); protocol adherence by facilitators (fidelity); protocol adherence by participants (dose received: exposure); participants and facilitators' opinion about the programme and perceived benefits and achievements (dose received: satisfaction); and experienced barriers and potential solutions for these (barriers) [21, 48, 49]. Table 3 provides a detailed overview of the outcomes of the process evaluation and their operationalisation during the course of the trial. Data is collected from participants in the programme group, and from the facilitators.

Table 3 Outcome measures of the process evaluation

Economic evaluation

A cost-effectiveness analysis is carried out in which costs are considered from a societal perspective. The economic evaluation measures and evaluates the 'real' costs. In this study, direct health-care costs are included; i.e. costs incurred by the in-home programme and health-care costs incurred by the participants. The costs of the programme consist of used materials, salaries of the facilitators, costs of training sessions for the facilitators etc. Health-care costs include hospital visits (inpatient and outpatient treatment), GP consultations, visits to paramedics, (nursing) home-care, informal care, and aids and appliances. In order to estimate the costs, the quantity of each resource will be multiplied by its assigned unit cost of price. Cost prices are obtained from the Dutch guidelines for cost analysis in health-care research [50, 51]. If such guidelines do not provide for specific health-care use, real costs or tariffs will be used to estimate costs.

Data collection

Data for the effect evaluation is gathered by means of telephone interviews which are conducted by trained interviewers, who are blinded for group allocation. For the assessment of fall accidents, participants received a fall calendar after the baseline measurement. Every month, a sheet of the calendar has to be returned via a freepost envelope. People are reminded by telephone after one-and-half weeks if a sheet is not returned.

The process evaluation data is gathered by several means. Participants who complete at least five sessions, fill in a questionnaire to report on the programme's feasibility and usefulness. Facilitators receive a registration form for each participant to report on the time spent per session, the participant's adherence with regard to homework assignments and the extent to which the programme is performed according to protocol. Voice recordings are used in a random selection of the sessions to gather objective data about the performance according to the protocol. Additionally, facilitators fill in questionnaires that assess their opinion about the programme for each participant and their overall opinion of the programme. Researchers conduct short telephone interviews to identify the reason(s) for withdrawal among people who do not complete the programme. Lastly, the researchers conduct a final evaluation meeting with the facilitators to discuss the overall programme.

The fall calendar mentioned before is also used for the collection of the data for the economic evaluation. Participants have to report their use of health-care services each month, in addition to their fall accidents.

Non-compliant participants of the programme group are approached for all follow-up measurements, and participants with missing data are contacted to ensure completion of data, as recommended by Hollis and Campbell [52].

Newsletters are sent 4 and 11 months after the baseline measurement, to keep the participants informed about the trial.

Sample size and power

Sample size calculations are based on outcomes of a previous study using the Falls Efficacy Scale-International (FES-I) among older people in The Netherlands [53]. Two times 112 participants will provide 80% power at alpha 0.05 (one-tailed) to detect differences between the intervention and control groups' mean score of at least 3.8 points (SD is 11.4 equivalent with an effect size of 0.33 on the FES-I). However, a dropout rate of 20% during the study is expected, based on the experiences in the home visit study from Van Haastregt et al. [54]. Therefore, 2 × 140 participants are needed to enrol in the trial.

In a previous Dutch study, 54% of the population reported fear of falling, 38% reported related avoidance behaviour, and 48% reported poor or fair perceived general health [8]. Based on the experiences in that study and on the evaluation of AMB-NL [15], we estimate that approximately 6% of the older people who return the screening questionnaire will meet all inclusion and exclusion criteria and will be interested in participating in the trial. With an estimated response rate of 55%, a minimum sample of 8,200 older persons aged 70 or over needs to be approached with a screening questionnaire.


Descriptive techniques will be used to describe the study groups. Baseline variables will be compared, to detect differences between the participants of both groups at the start of the study. Data of the effect evaluation will be analysed according to both the intention-to-treat and per-protocol principles. In the first analyses all participants will be included according to their original assignment [52]. Participants of the intervention group who attended at least five of the seven programme sessions will be included in the per-protocol analysis. Based on prior work, five sessions of the programme are considered as sufficient programme exposure [15, 18]. Mixed-effects regression analyses will be applied, to test for between-group differences with respect to the primary, secondary and tertiary outcome measures at all follow-up assessments. Models will be adjusted for the following covariates, considered as relevant for the outcomes [8]: concerns about falls, age, gender, perceived general health, and number of falls in the past 6 months at baseline. Additional covariates will be included in the analysis if baseline differences are detected for variables relevant for the outcomes. The level of statistical significance will be set at 0.05 (one-tailed). Data on the process and economic evaluation will be analysed and presented using descriptive techniques and appropriate statistical testing.


A multicomponent cognitive behavioural in-home programme has been developed to teach frail older people living in the community how to manage their concerns about falls and related activity avoidance. A trial was conducted to evaluate this programme on effectiveness, feasibility and costs. The screening procedure for eligible participants started in March 2009. For practical reasons, the procedure is distributed across four cycles, that last of which was in December 2009. In the first cycle, 2,250 older people living in the south-east of The Netherlands received the screening questionnaire. Enrolment into the study was disappointing during this cycle. Therefore, we decided to send out more screening questionnaires than planned in the next cycles, and to broaden the inclusion criteria from regular to both some concerns about falls and some avoidance of activity. In addition, responders entered a draw to win one of the fifteen gift vouchers worth € 25. Eventually, 11,490 older people received the screening questionnaire across the four cycles. The response rate was 52.6% and by applying the modified inclusion criteria, 389 participants were included into the study.

Changes made in the treatment protocol of the group programme while adapting it for the individual in-home application may influence effectiveness. First, the physical exercises from the group approach were removed from the programme, because the facilitator could not monitor them adequately during the telephone contacts. Instead, more attention is given to action plans and overcoming a more challenging (fear-related) problem in daily life in session 5. Second, by sending huge numbers of questionnaires, we choose a screening procedure to include enough participants in a relatively short period of time. This is also the reason why participants did not receive a personal assessment in which they are tested on, for example, physical performances, such as balance and strength, and motivation. With this procedure, we may have missed helpful information about how realistic the participants' concerns about falls are and, how much they are prepared to do something about their concerns. In the future, possibilities for testing participants' physical performance [55] and motivation at the start of the programme might be explored [56]. Third, to make implementation in the Dutch health-care setting more acceptable, we have chosen for community nurses as facilitators. Yet, these nurses have little experience of facilitating behavioural change; instead, they are usually trained to provide care and information. In this programme, they were also expected to act as a personal coach to the participants, and to encourage self-management skills. This might have put additional demands on them as facilitators, for which they may not have been trained in the past. Therefore, and to increase the treatment integrity of the programme, nurses received specific training prior to the start of the project. Lastly, the use of telephone contacts as part of the programme is rather new among this older population, in particular, and nurses from home-care organisations in the Netherlands. If successful, the results might lead to a more cost-effective programme and promising prospects for further use of telephone contacts in programmes with frail older people in the future.

Progress of the study

The baseline measurements started in March 2009. Data on the effect, process and economic evaluation are expected to be available in 2012.

Future implementation

During the last two years the successful group programme AMB-NL has been implemented nationwide into the Dutch health-care setting. Details about the programme are presented on the Dutch website If the results of the current trial show effectiveness and feasibility of AMB-Home, then the in-home programme can be offered to people who are not able or willing to participate in the group programme.



The Dutch in-home version of A Matter of Balance


The Dutch group version of A Matter of Balance


  1. 1.

    Masud T, Morris RO: Epidemiology of falls. Age Ageing. 2001, 30: 3-7. 10.1093/ageing/30.1.3.

    Article  PubMed  Google Scholar 

  2. 2.

    Rubenstein LZ: Falls in older people: epidemiology, risk factors and strategies for prevention. Age Ageing. 2006, 35: 37-41. 10.1093/ageing/afj018.

    Article  Google Scholar 

  3. 3.

    Arfken CL, Lach HW, Birge SJ, Miller JP: The Prevalence and Correlates of Fear of Falling in Elderly Persons Living in the Community. Am J Public Health. 1994, 84 (4): 565-570. 10.2105/AJPH.84.4.565.

    CAS  Article  PubMed  PubMed Central  Google Scholar 

  4. 4.

    Fletcher PC, Hirdes JP: Restriction in activity associated with fear of falling among community-based seniors using home care services. Age Ageing. 2004, 33 (3): 273-279. 10.1093/ageing/afh077.

    Article  PubMed  Google Scholar 

  5. 5.

    Howland J, Lachman ME, Peterson EW, Cote J, Kasten L, Jette A: Covariates of fear of falling and associated activity curtailment. Gerontologist. 1998, 38 (5): 549-555. 10.1093/geront/38.5.549.

    CAS  Article  PubMed  Google Scholar 

  6. 6.

    Murphy SL, Williams CS, Gill TM: Characteristics associated with fear of falling and activity restriction in community-living older persons. J Am Geriatr Soc. 2002, 50 (3): 516-520. 10.1046/j.1532-5415.2002.50119.x.

    Article  PubMed  PubMed Central  Google Scholar 

  7. 7.

    Tinetti ME, Mendes de Leon CF, Doucette JT, Baker DI: Fear of falling and fall-related efficacy in relationship to functioning among community-living elders. J Gerontol. 1994, 49 (3): M140-147.

    CAS  Article  PubMed  Google Scholar 

  8. 8.

    Zijlstra GA, van Haastregt JC, van Eijk JT, van Rossum E, Stalenhoef PA, Kempen GI: Prevalence and correlates of fear of falling, and associated avoidance of activity in the general population of community-living older people. Age Ageing. 2007, 36 (3): 304-309. 10.1093/ageing/afm021.

    CAS  Article  PubMed  Google Scholar 

  9. 9.

    Yardley L, Smith H: A prospective study of the relationship between feared consequences of falling and avoidance of activity in community-living older people. Gerontologist. 2002, 42 (1): 17-23. 10.1093/geront/42.1.17.

    Article  PubMed  Google Scholar 

  10. 10.

    Cumming RG, Salkeld G, Thomas M, Szonyi G: Prospective study of the impact of fear of falling on activities of daily living, SF-36 scores, and nursing home admission. J Gerontol A-Biol. 2000, 55 (5): M299-M305. 10.1093/gerona/55.5.M299.

    CAS  Article  Google Scholar 

  11. 11.

    Delbaere K, Close JCT, Brodaty H, Sachdev P, Lord SR: Determinants of disparities between perceived and physiological risk of falling among elderly people: cohort study. Brit Med J. 2010, 341: c4165.

    Article  PubMed  PubMed Central  Google Scholar 

  12. 12.

    Friedman SM, Munoz B, West SK, Rubin GS, Fried LP: Falls and fear of falling: Which comes first? A longitudinal prediction model suggests strategies for primary and secondary prevention. J Am Geriatr Soc. 2002, 50 (8): 1329-1335. 10.1046/j.1532-5415.2002.50352.x.

    Article  PubMed  Google Scholar 

  13. 13.

    Delbaere K, Sturnieks DL, Crombez G, Lord SR: Concern About Falls Elicits Changes in Gait Parameters in Conditions of Postural Threat in Older People. J Gerontol A-Biol. 2009, 64 (2): 237-242.

    Article  Google Scholar 

  14. 14.

    Hadjistavropoulos T, Delbaere K, Fitzgerald TD: Reconceptualizing the Role of Fear of Falling and Balance Confidence in Fall Risk. J Aging Health. 2011, 23 (1): 3-23. 10.1177/0898264310378039.

    Article  PubMed  Google Scholar 

  15. 15.

    Zijlstra GA, van Haastregt JC, Ambergen T, van Rossum E, van Eijk JT, Tennstedt SL, Kempen GI: Effects of a multicomponent cognitive behavioral group intervention on fear of falling and activity avoidance in community-dwelling older adults: results of a randomized controlled trial. J Am Geriatr Soc. 2009, 57 (11): 2020-2028. 10.1111/j.1532-5415.2009.02489.x.

    Article  PubMed  Google Scholar 

  16. 16.

    Brouwer BJ, Walker C, Rydahl SJ, Culham EG: Reducing fear of falling in seniors through education and activity programs: A randomized trial. J Am Geriatr Soc. 2003, 51 (6): 829-834. 10.1046/j.1365-2389.2003.51265.x.

    Article  PubMed  Google Scholar 

  17. 17.

    Clemson L, Cumming RG, Kendig H, Swann M, Heard R, Taylor K: The effectiveness of a community-based program for reducing the incidence of falls in the elderly: A randomized trial. J Am Geriatr Soc. 2004, 52 (9): 1487-1494. 10.1111/j.1532-5415.2004.52411.x.

    Article  PubMed  Google Scholar 

  18. 18.

    Tennstedt S, Howland J, Lachman M, Peterson E, Kasten L, Jette A: A randomized, controlled trial of a group intervention to reduce fear of falling and associated activity restriction in older adults. J Gerontol B-Psychol. 1998, 53 (6): P384-P392.

    CAS  Article  Google Scholar 

  19. 19.

    Bula CJ, Monod S, Hoskovec C, Rochat S: Interventions Aiming at Balance Confidence Improvement in Older Adults: An Updated Review. Gerontology. 2011, 57 (3): 276-286. 10.1159/000322241.

    Article  PubMed  Google Scholar 

  20. 20.

    Zijlstra GA, Tennstedt SL, van Haastregt JC, van Eijk JT, Kempen GI: Reducing fear of falling and avoidance of activity in elderly persons: the development of a Dutch version of an American intervention. Patient Educ Couns. 2006, 62 (2): 220-227. 10.1016/j.pec.2005.07.005.

    Article  PubMed  Google Scholar 

  21. 21.

    van Haastregt JC, Zijlstra GA, van Rossum E, van Eijk JT, de Witte LP, Kempen GI: Feasibility of a cognitive behavioural group intervention to reduce fear of falling and associated avoidance of activity in community-living older people: a process evaluation. BMC Health Serv Res. 2007, 7: 156-10.1186/1472-6963-7-156.

    Article  PubMed  PubMed Central  Google Scholar 

  22. 22.

    Sattin RW, Easley KA, Wolf SL, Chen Y, Kutner MH: Reduction in fear of falling through intense tai chi exercise training in older, transitionally frail adults. J Am Geriatr Soc. 2005, 53 (7): 1168-1178. 10.1111/j.1532-5415.2005.53375.x.

    Article  PubMed  Google Scholar 

  23. 23.

    Stewart AL, Hays RD, Ware JE: The Mos Short-Form General Health Survey - Reliability and Validity in a Patient Population. Med Care. 1988, 26 (7): 724-732. 10.1097/00005650-198807000-00007.

    CAS  Article  PubMed  Google Scholar 

  24. 24.

    Swain DG, Nightingale PG: Evaluation of a shortened version of the Abbreviated Mental Test in a series of elderly patients. Clin Rehabil. 1997, 11 (3): 243-248. 10.1177/026921559701100308.

    CAS  Article  PubMed  Google Scholar 

  25. 25.

    Kempen GI, Meier AJ, Bouwens SF, van Deursen J, Verhey FR: [The psychometric properties of the Dutch version of the Telephone Interview Cognitive Status (TICS)]. Tijdschr Gerontol Geriatr. 2007, 38 (1): 38-45.

    CAS  Article  PubMed  Google Scholar 

  26. 26.

    Zijlstra GAR, van Haastregt JCM, van Eijk JTM, de Witte LP, Ambergen T, Kempen GIJM: Mediating effects of psychosocial factors on concerns about falling and daily activity in a multicomponent cognitive behavioral group intervention. Aging Ment Health. 2011, 15 (1): 68-77. 10.1080/13607863.2010.501054.

    Article  PubMed  Google Scholar 

  27. 27.

    Lachman ME, Jette A, Tennstedt S, Howland J, Harris BA, Peterson E: A cognitive-behavioural model for promoting regular physical activity in older adults. Psychology, Health & Medicine. 1997, 2 (3): 251-261. 10.1080/13548509708400583.

    Article  Google Scholar 

  28. 28.

    Resnicow K, Dilorio C, Soet JE, Borrelli B, Hecht J, Ernst D: Motivational interviewing in health promotion: It sounds like something is changing. Health Psychol. 2002, 21 (5): 444-451.

    Article  PubMed  Google Scholar 

  29. 29.

    Delbaere K, S TS, Lord SR: Development and initial validation of the iconographical falls efficacy scale. J Gerontol A-Biol. 2011, 66 (6): 674-680.

    Article  Google Scholar 

  30. 30.

    Ziegelmann JP, Lippke S, Schwarzer R: Adoption and maintenance of physical activity: Planning interventions in young, middle-aged, and older adults. Psychology & Health. 2006, 21 (2): 145-163.

    Article  Google Scholar 

  31. 31.

    Vlaeyen JWS, de Jong J, Geilen M, Heuts PHTG, van Breukelen G: The treatment of fear of movement/(re)injury in chronic low back pain: Further evidence on the effectiveness of exposure in vivo. Clin J Pain. 2002, 18 (4): 251-261. 10.1097/00002508-200207000-00006.

    Article  PubMed  Google Scholar 

  32. 32.

    Lorig KR, Holman H: Self-management education: history, definition, outcomes, and mechanisms. Ann Behav Med. 2003, 26 (1): 1-7. 10.1207/S15324796ABM2601_01.

    Article  PubMed  Google Scholar 

  33. 33.

    Yardley L, Beyer N, Hauer K, Kempen G, Piot-Ziegler C, Todd C: Development and initial validation of the Falls Efficacy Scale-International (FES-I). Age Ageing. 2005, 34 (6): 614-619. 10.1093/ageing/afi196.

    Article  PubMed  Google Scholar 

  34. 34.

    Kempen GI, Zijlstra GA, van Haastregt JC: [The assessment of fear of falling with the Falls Efficacy Scale-International (FES-I). Development and psychometric properties in Dutch elderly]. Tijdschr Gerontol Geriatr. 2007, 38 (4): 204-212.

    CAS  Article  PubMed  Google Scholar 

  35. 35.

    Kempen GIJM, Miedema I, Ormel J, Molenaar W: The assessment of disability with the Groningen Activity Restriction Scale. Conceptual framework and psychometric properties. Soc Sci Med. 1996, 43 (11): 1601-1610. 10.1016/S0277-9536(96)00057-3.

    CAS  Article  PubMed  Google Scholar 

  36. 36.

    Falls KIWGotPo: The prevention of falls in later life. A report of the Kellogg International Work Group on the Prevention of Falls by the Elderly. Dan Med Bull. 1987, 34 (Suppl 4): 1-24.

    Google Scholar 

  37. 37.

    Delbaere K, Crombez G, van Haastregt JCM, Vlaeyen JWS: Falls and catastrophic thoughts about falls predict mobility restriction in community-dwelling older people: A structural equation modelling approach. Aging Ment Health. 2009, 13 (4): 587-592. 10.1080/13607860902774444.

    Article  PubMed  Google Scholar 

  38. 38.

    Lawrence RH, Tennstedt SL, Kasten LE, Shih J, Howland J, Jette AM: Intensity and correlates of fear of falling and hurting oneself in the next year - Baseline findings from a Roybal center fear of falling intervention. J Aging Health. 1998, 10 (3): 267-286. 10.1177/089826439801000301.

    CAS  Article  PubMed  Google Scholar 

  39. 39.

    Pearlin LI, Schooler C: The structure of coping. J Health Soc Behav. 1978, 19 (1): 2-21. 10.2307/2136319.

    CAS  Article  PubMed  Google Scholar 

  40. 40.

    Bjelland I, Dahl AA, Haug TT, Neckelmann D: The validity of the Hospital Anxiety and Depression Scale. An updated literature review. J Psychosom Res. 2002, 52 (2): 69-77. 10.1016/S0022-3999(01)00296-3.

    Article  PubMed  Google Scholar 

  41. 41.

    Spinhoven P, Ormel J, Sloekers PPA, Kempen GIJM, Speckens AEM, VanHemert AM: A validation study of the Hospital Anxiety and Depression Scale (HADS) in different groups of Dutch subjects. Psychol Med. 1997, 27 (2): 363-370. 10.1017/S0033291796004382.

    CAS  Article  PubMed  Google Scholar 

  42. 42.

    Kempen GIJM, Vaneijk LM: The Psychometric Properties of the Ssl12-I, a Short Scale for Measuring Social Support in the Elderly. Social Indicators Research. 1995, 35 (3): 303-312. 10.1007/BF01079163.

    Article  Google Scholar 

  43. 43.

    Gandek B, Ware JE, Aaronson NK, Apolone G, Bjorner JB, Brazier JE, Bullinger M, Kaasa S, Leplege A, Prieto L, et al: Cross-validation of item selection and scoring for the SF-12 Health Survey in nine countries: results from the IQOLA Project. International Quality of Life Assessment. J Clin Epidemiol. 1998, 51 (11): 1171-1178. 10.1016/S0895-4356(98)00109-7.

    CAS  Article  PubMed  Google Scholar 

  44. 44.

    Kempen GI: [Assessment of health status of the elderly. Application of a Dutch version of the MOS scale]. Tijdschr Gerontol Geriatr. 1992, 23 (4): 132-140.

    CAS  PubMed  Google Scholar 

  45. 45.

    van Sonsbeek JLA: Methodological aspects and content of the OECD-longterm disability indicator. CBS Maandberichten Gezondheid. 1988, 6: 4-17.

    Google Scholar 

  46. 46.

    CBS: Gezondheidsenquete 1989 (Health Interview Survey). 1989, Voorburg/Heerlen, The Netherlands

    Google Scholar 

  47. 47.

    Goossens MEJB, Vlaeyen JWS, Hidding A, Kole-Snijders A, Evers SMAA: Treatment expectancy affects the outcome of cognitive-behavioral interventions in chronic pain. Clin J Pain. 2005, 21 (1): 18-26. 10.1097/00002508-200501000-00003.

    Article  PubMed  Google Scholar 

  48. 48.

    Zijlstra GAR, van Rens GHMB, Scherder EJA, Brouwer DM, van der Velde J, Verstraten PFJ, Kempen GIJM: Effects and feasibility of a standardised orientation and mobility training in using an identification cane for older adults with low vision: design of a randomised controlled trial. BMC Health Serv Res. 2009, 9: 153-10.1186/1472-6963-9-153.

    CAS  Article  PubMed  PubMed Central  Google Scholar 

  49. 49.

    Saunders RP, Evans MH, Joshi P: Developing a process-evaluation plan for assessing health promotion program implementation: a how-to guide. Health Promot Pract. 2005, 6 (2): 134-147. 10.1177/1524839904273387.

    Article  PubMed  Google Scholar 

  50. 50.

    Oostenbrink JB, Koopmanschap MA, Rutten FFH: Handleiding voor kostenonderzoek: methoden en richtlijnprijzen voor economische evaluaties in de gezondheidszorg. 2000, Amstelveen: College voor zorgverzekeringen

    Google Scholar 

  51. 51.

    Oostenbrink JB, Koopmanschap MA, Rutten FFH: Standardisation of costs - The Dutch manual for costing in economic evaluations. Pharmacoeconomics. 2002, 20 (7): 443-454. 10.2165/00019053-200220070-00002.

    Article  PubMed  Google Scholar 

  52. 52.

    Hollis S, Campbell F: What is meant by intention to treat analysis? Survey of published randomised controlled trials. Brit Med J. 1999, 319 (7211): 670-674.

    CAS  Article  PubMed  PubMed Central  Google Scholar 

  53. 53.

    Kempen GI, Todd CJ, Van Haastregt JC, Zijlstra GA, Beyer N, Freiberger E, Hauer KA, Piot-Ziegler C, Yardley L: Cross-cultural validation of the Falls Efficacy Scale International (FES-I) in older people: results from Germany, the Netherlands and the UK were satisfactory. Disabil Rehabil. 2007, 29 (2): 155-162. 10.1080/09638280600747637.

    Article  PubMed  Google Scholar 

  54. 54.

    van Haastregt JC, Diederiks JP, van Rossum E, de Witte LP, Voorhoeve PM, Crebolder HF: Effects of a programme of multifactorial home visits on falls and mobility impairments in elderly people at risk: randomised controlled trial. Brit Med J. 2000, 321 (7267): 994-998. 10.1136/bmj.321.7267.994.

    CAS  Article  PubMed  PubMed Central  Google Scholar 

  55. 55.

    Persad CC, Cook S, Giordani B: Assessing falls in the elderly: should we use simple screening tests or a comprehensive fall risk evaluation?. Eur J Phys Rehabil Med. 2010, 46 (2): 249-259.

    CAS  PubMed  Google Scholar 

  56. 56.

    Prochaska JO, DiClemente CC: Stages and processes of self-change of smoking: toward an integrative model of change. J Consult Clin Psychol. 1983, 51 (3): 390-395.

    CAS  Article  PubMed  Google Scholar 

Pre-publication history

  1. The pre-publication history for this paper can be accessed here:

Download references

Acknowledgements and Funding

We would like to thank the municipal registry offices of Maastricht, Heerlen and Sittard-Geleen, the Centre for Data and Information Management (MEMIC) and research assistant Yvonne van Eijs for their assistance in this study. We would also like to thank the experts Jolanda van Haastregt (Vivre) and José Grouls (Meandergroep) who, in addition to the authors of this article, contributed to the development of the programme protocol. This research has been funded by ZonMw, The Netherlands Organisation for Health Research and Development (grant 120610001). The participation of author JV was supported by the Odysseus Grant 'The Psychology of Pain and Disability Research Programme' funded by the Research Foundation, Flanders, Belgium (FWO Vlaanderen).

Author information



Corresponding author

Correspondence to Tanja AC Dorresteijn.

Additional information

Competing interests

The authors declare that they have no competing interests.

Authors' contributions

GK and RZ developed the project and obtained funding. All authors participated in the final design of the study. TD is the researcher on the project. TD, RZ and GK developed the materials for the study and received input from the other authors, particularly KD. TD wrote the first draft of this paper and the other authors provided input. All authors read and approved the final manuscript.

Authors’ original submitted files for images

Below are the links to the authors’ original submitted files for images.

Authors’ original file for figure 1

Rights and permissions

This article is published under license to BioMed Central Ltd. This is an Open Access article distributed under the terms of the Creative Commons Attribution License (, which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited.

Reprints and Permissions

About this article

Cite this article

Dorresteijn, T.A., Zijlstra, G.R., Delbaere, K. et al. Evaluating an in-home multicomponent cognitive behavioural programme to manage concerns about falls and associated activity avoidance in frail community-dwelling older people: Design of a randomised control trial [NCT01358032]. BMC Health Serv Res 11, 228 (2011).

Download citation


  • Activity Avoidance
  • Telephone Contact
  • Group Programme
  • Screen Questionnaire
  • Protocol Adherence