The effect of limited English proficiency on falls risk and falls prevention after stroke

SIR—Language barriers disadvantage the health care of people with limited English proficiency (LEP) [1]. For people with stroke, having LEP has been associated with increased length of hospital stay [2] and underutilisation of anticoagulants [3]. There remain many gaps in the evidence regarding health care for stroke patients with LEP as researchers frequently exclude this group from studies. Falling is an adverse event for many stroke survivors. Up to 73% of people with stroke fall during the first 6 months after discharge home [4, 5]. Despite recent interest in falls prevention for people with stroke, [6] falls risk and falls prevention after stroke for people with LEP has not been specifically explored. The objective of this sub-study analysis of a randomised controlled trial was to determine if having LEP affected overall falls risk, falls risk factors, falls prevention strategies or planned health and support service use for community-dwelling people at risk of recurrent falls after stroke. Data were extracted from the baseline assessment of a randomised controlled trial that evaluated the effectiveness of a multi-factorial falls prevention programme for stroke survivors who were at high risk of falling on return home after rehabilitation [7]. Adults who returned home after stroke rehabilitation were eligible for the study if they were at risk of recurrent falls (decreased balance or had fallen at any time during their hospital admission). Decreased balance was defined as a step test worst leg score of less than 7 or a Berg Balance Scale score of less than 49 [5]. Potential participants were excluded if they were being discharged to residential care or living ≥100 km from study sites. Participants were recruited from nine rehabilitation units in two Australian cities with established migrant communities, Melbourne and Adelaide. Participants were categorised as LEP if they required an interpreter during their assessment. Treating physiotherapists assessed eligibility and provided study information prior to the patient's discharge from inpatient care. Potential participants were contacted 2 weeks after discharge to arrange assessment. Participants who had used an interpreter during inpatient care were offered a professional interpreter or they could choose to use an informal interpreter. All assessments were conducted in participants' homes prior to randomisation. Falls risk was measured using the Falls Risk for Older People in the Community (FROP-com) tool which has been demonstrated to have good reliability and moderate capacity to predict falls for community-dwelling older people [8]. Gait speed over 5 m [9] and the Timed Up and Go test (TUG) [10] were measured. Activity was assessed with the Human Activity Profile Adjusted Activity Score (HAPAAS), [11] and FIM™ [12] was used as a measure of functional independence. Checklists were completed for falls prevention strategies in place and planned use of health and support services. Comparisons were made between groups using t-tests for continuous data and χ2 for categorical data with PASW 18.0 software (alpha = 0.05, two-tailed for significance). Relevant human research ethics committees approved the study. Information and consent forms were interpreted in each participant's preferred language and participants or next of kin provided written consent. Twenty stroke survivors who had LEP (LEP group) and 136 stroke survivors who were proficient in English (EP group) were assessed a mean of 15 days (SD 11) following discharge from rehabilitation. In the LEP group, nine languages were spoken: Croatian (1), Greek (1), Hakka (1), Italian (7), Macedonian (2), Mandarin (2), Russian (1), Spanish (1), and Vietnamese (4). Six participants with LEP used a professional interpreter during assessment and 14 used an informal interpreter; either a partner (4) or adult relative (10). There were no significant differences on any demographic characteristics except for living arrangements (Table 1). The larger than expected number in the category ‘living with family’ for the LEP group contributed greatest to this difference (standardised residual 3.9). No more than one of the LEP group (5%) and five of the EP group (9%) had missing data. Participant characteristics aχ2 not reported as more than 20% of cells contain frequency <5. Participant characteristics aχ2 not reported as more than 20% of cells contain frequency <5. The mean total FROP-com score was significantly higher for the LEP group (Table 2) indicating higher falls risk [8]. However, inspection of individual components of the FROP-com revealed that the LEP group had lower scores on the Abbreviated Mental Test Score (AMTS) component. Concerned that the AMTS may have been subject to cultural bias, [13] FROP-com scores were re-analysed with the AMTS removed and the resultant difference between groups was no longer statistically significant (Table 2). Diabetes (LEP 10/50%, EP 36/26.7%, χ2, P = 0.033) and dizziness (LEP 9/45%, EP 30/22.1%, χ2, P = 0.027) were more prevalent in the LEP group. A significantly greater percentage of participants with LEP reported needing assistance with activities of daily living (Table 2). The LEP group's activity levels (HAPAAS) were significantly lower and they were slower on gait speed and TUG (Table 2). Differences in falls risk, falls risk factors, falls prevention strategies and planned health and support service use between groups aχ2 not reported as more than 20% of cells contain frequency <5. Differences in falls risk, falls risk factors, falls prevention strategies and planned health and support service use between groups aχ2 not reported as more than 20% of cells contain frequency <5. Both groups averaged between seven and eight falls prevention strategies in place by the time of assessment (LEP 7.4, EP 8.0). Significantly less of the LEP group reported exercising at home or in the community (LEP 11/55.0%, EP 106/77.9%, χ2, P = 0.027). There was no significant difference between groups for other strategies. Please see figure in Supplementary data available in Age and Ageing online, Appendix 1. Participants with LEP planned to access, or had accessed, significantly fewer services in the home (Table 2). The use of home help was the only individual service significantly different between groups (LEP 2/10%, EP 60/44%, χ2, P = 0.004). An occupational therapist visit was the most reported service provided in the home (LEP 14/70%, EP 110/80.9%) and a visit to the local doctor was the most reported community service in both groups (LEP 17/85%, EP 112/82.45%). A physiotherapist visit was planned by at least half the participants of both groups (LEP 10/50%, 93/68.4%). Day centres were accessed least in both groups (LEP 0, EP 2/1.5%). Please see table in Supplementary data available in Age and Ageing online, Appendix 2. This is the first study to explore the relationship between English language proficiency, falls risk and falls prevention. The number of languages spoken in this sample is reflective of the linguistic diversity in many ageing multicultural communities. Worse gait and balance ability, lower reported activity levels, and a greater need for assistance with activities of daily living suggest that stroke survivors with LEP at risk of falling may be going home frailer than EP stroke survivors. The acceptance of fewer services in the home by the LEP group and a higher proportion living with extended family imply that informal carers are ‘filling the gap’ in services for this group. The primacy of family in the home care of older ethnic people has been reported, [14] but assumptions of cultural expectation may mask language and practical difficulties. Health professionals can support informal carers of people with LEP by ensuring they have adequate training and access to support services. The local doctor was the main health care contact for most participants. This concurs with research exploring the falls risk information needs of Chinese–Australians [15]. The moderately high level of physiotherapy reported by both groups supports the uptake of allied health professionals for the community management of falls risk after stroke. The significantly lower proportion of participants with LEP exercising is a concern for both overall stroke recovery and falls risk management in this group. People with LEP are reported to be less likely to follow recommendations for treatment [1] and engage in less healthy exercise behaviours [16]. Increasing exercise participation by stroke survivors with LEP warrants further clinical and research attention. The study is limited by small numbers in the LEP group and post hoc analysis. Despite interpreting all assessment tools, the use of informal interpreters by some may have affected the accuracy of translation and some self-report measures may not always have been culturally appropriate [13]. Conceptual and functional equivalence of self-report measures needs to be considered when selecting falls risk tools for research with multicultural communities, a significant challenge when many languages are represented [17]. In conclusion, this study was the first step in investigating falls risk and falls prevention for people with LEP. Findings suggest that LEP may have an effect on falls risk and health service use after stroke for people at risk of recurrent falls. Further research is needed to demonstrate the effect in a larger sample and to understand why these differences may exist. LEP may affect the pattern of falls risk and service use for people with high falls risk after stroke. Extended families are important for the falls risk management of stroke survivors with LEP. Falls risk evaluations in multicultural communities must consider the cultural appropriateness of included measures. None declared. This work was supported by the Australian National Health and Medical Research Council (NHMRC ID: 385002, NHMRC Health Professional Training Fellowship ID: 310612 to C.S.).