The Effect of Empowerment Based on 5A Model on Fall Self-Efficacy, Self-Care and Quality of Life in Older Adults: A Parallel Randomized Clinical Trial

doi:10.21203/rs.3.rs-4873098/v1

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The Effect of Empowerment Based on 5A Model on Fall Self-Efficacy, Self-Care and Quality of Life in Older Adults: A Parallel Randomized Clinical Trial

https://doi.org/10.21203/rs.3.rs-4873098/v1

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Background: With aging and declining functional abilities in older adults, the fear of falling increases, leading to decrease in quality of life. Self-care is an important factor in maintaining older adults' overall health and quality of life. This study aimed to determine the effect of empowerment via the 5A model on fall self-efficacy, self-care, and quality of life in older adults.

Methods: This clinical trial study was conducted with 110 elderly individuals residing in the community. The participants were selected via a sequential sampling method and were allocated to the control and intervention groups viablock randomization in sets of four. The control group received routine care from comprehensive health service centers, whereas the intervention group received 5A model-based empowerment over a 12-week program. The data collection instruments included a demographic characteristics form and questionnaires such as the Activities-Specific Balance Confidence Scale, the WHO-5 Well-Being, and the Elderly Self-Care, which were completed before random allocation and after the twelfth week. The data were analyzed using chi-square tests, Fisher's exact tests, independent t-tests, and analysis of covariance.

Results: The mean and standard deviation (SD) of the participants' age were 68.28±3.14. The mean differences in the scores of fall self-efficacy (p<0.001), self-care (p<0.001), and quality of life (p<0.001) before and after the intervention were significantly different between the control and intervention groups.

Conclusion: Empowerment based on the 5A model led to improvements in fall self-efficacy, self-care, and quality of life among older adults. Health caregivers and nurses can utilize this model to increase fall self-efficacy, reduce fear of falling, improve self-care, and improve quality of life among older adults, as well as to design care programs.

Trial registration:Iranian Registry of Clinical Trials (IRCT20221231057000N2; 11/12/2023)

Empowerment

Falls Self-Efficacy

Fear of Falling

Older Adults

Quality of Life

Self-Care

Self-Management

5A Model

Fear of falling (FoF) is a common health issue among older adults (1). FoF refers to low self-confidence and low perceived self-efficacy in preventing falls during certain daily life activities (2, 3). A mild FOF is a protective response that discourages behaviors that increase the risk of falls, whereas severe fear can increase the risk of falling (4). A systematic review estimated that the overall prevalence of FOF among older adults was 49.6% (1). FoF may be triggered by a previous fall experience. On average, 55% of older adults who have experienced a fall develop a fear of falling (5). FOF can develop in older adults even without a history of falls, often due to age-related changes such as muscle weakness and functional decline. This fear can lead to depression, decreased self-efficacy, and social isolation (6). Among other consequences, reduced physical function and mobility can be observed, leading to muscle atrophy (4). Furthermore, FOF in older adults may lead to changes in gait and an increased risk of falling (1). FOF affects the ability of elderly people to perform activities of daily living, thereby reducing their independence (7). Enhancing self-efficacy can play a significant role in reducing the fear of falling (3, 8). Fall self-efficacy is defined as an individual's belief in their ability to perform daily activities without falling or losing balance (3, 9, 10). A deeper understanding of fall self-efficacy can lead to the development of more effective strategies for preventing falls and mitigating their associated consequences, such as fear of falling (11). Furthermore, enhancing self-efficacy can effectively contribute to behavior modification and increased motivation (8).

FOF can limit self-care activities, leading to decreased balance and muscle strength, thereby increasing the risk of falls (12). According to the WHO, self-care is the ability of individuals, families, and communities to promote and maintain health, prevent illness, and cope with illness and disability with or without the support of healthcare providers (13). Self-care can empower older adults to gain respect of others and achieve greater self-satisfaction (14). Individuals' focus on self-care can enhance their quality of life, maintain their functional status, and reduce disability and hospitalization (15). Through self-care, elderly people can manage their daily lives and improve their well-being. Furthermore, older adults can maintain or improve their health status through self-care (16).

Fear of falling is a significant factor contributing to a decreased quality of life among older adults (2, 5). Quality of life reflects an individual's overall well-being (17) and is closely linked to active aging. Thus, maintaining quality of life in older adults is influenced by determinants of active aging, such as the physical and social environment; health and social services; and economic, personal, and behavioral factors (18). An individual's mental quality of life can be assessed through their feelings towards psychological well-being (19). Quality of life is interconnected with multiple dimensions of well-being, including an individual’s or group's physical, psychological, and social well-being (20). According to the WHO, quality of life is defined as an individual's perception of their position in life in the context of the culture and the values related to their goals, expectations, standards and concerns (20). Older adults can achieve a greater quality of life when they are competent to perform activities of daily living (ADL) independently, leading to improved well-being (21).

By implementing various programs and interventions, including self-management programs, healthcare providers and policymakers aim to increase health and well-being and prevent diseases in older adults (13). Self-management is correlated with empowerment and is an important component of it (22). The 5A model is an empowerment and self-management program that employs an evidence-based approach to behavior change (22, 23). This model was derived from the 4A framework, which was originally developed by the National Cancer Institute for smoking cessation interventions (24). A Canadian working group subsequently recommended the addition of a step (Agree) to provide behavioral counselling to assist patients (24). Additionally, this model was further developed by Whitlock and Glasgow (24, 25). This model is implemented in five steps: assess, Advise, Agree, Assist, and Arrange (25). The advantages of the 5A model are patient-centeredness, care based on collaborative planning and agreed upon by both the client and the educator, and active patient involvement in decision-making about treatment and self-care (22, 25). Self-management programs are utilized not only for hospitalized patients and those with chronic conditions but also for healthy individuals to prevent diseases and improve unhealthy behaviors (22). Studies have shown that the 5A model can enhance patients' self-management knowledge and self-efficacy (22, 26).

Reviews of previous studies have examined various aspects of this model, including its effectiveness. The 5A model has been applied in various studies, such as Amiri et al. (2022) to increase self-efficacy among stroke patients (27) and Keyvan et al. (2023) to improve quality of life in hemodialysis patients (23); furthermore, other studies have utilized this model to enhance self-care and quality of life in hypertensive elderly individuals (28), as well as to promote self-efficacy and empowerment in elderly individuals with diabetes (22, 26). However, a study conducted by Javanoush et al. (2018) did not reveal a significant effect of the 5A self-management model on the quality of life of elderly patients with acute coronary syndrome (29). Although numerous studies have been conducted on the 5A model, no research has examined the model's effectiveness in improving fall self-efficacy, self-care, and quality of life among older adults. Therefore, this study aimed to determine the effect of empowerment via the 5A model on fall self-efficacy, self-care, and quality of life in older adults.

Design and setting of the study

This study was a parallel randomized clinical trial. This clinical trial has been registered in the Iranian Registry of Clinical Trials (IRCT) with the registration number IRCT20221231057000N2. In this clinical trial, participants were randomly assigned to either the intervention or control group. The setting for this study was comprehensive health service centers in the urban areas of Gorgan, Golestan Province.

Participant characteristics

The study population included all individuals aged 65 years and older from urban community dwellers in the city of Gorgan. Participants who referred to comprehensive health service centers, 110 eligible participants were selected via a consecutive sampling method. The city of Gorgan is divided into three municipal districts. Two centers were randomly selected from each district, and samples were selected proportionally from elderly community dwellers.

The inclusion criteria were as follows: age 65 years and older; orientation to time, place, and person; ability to comprehend educational instructions; independence in activities of daily living as measured by a Katz ADL (score of 5 or 6); and a Mini-Mental State Examination score greater than 18. The exclusion criteria for the participants included those who were diagnosed with physical or psychiatric illnesses and those concurrently enrolled in similar educational programs.

To determine the sample size for each dependent variable, the following formulas were considered on the basis of similar studies. For the outcome of fall self-efficacy, using the study of Sadeghigolafshani et al. and considering a type I error of 0.05 and a power of 85%, the required sample size was estimated to be 30 people per group (26). For the outcomes of self-care and quality of life, using the study by Asgharian et al. and considering a type I error of 0.05 and a power of 85%, the required sample sizes were estimated to be 49 and 26 people per group, respectively (28). Considering the maximum sample size and a 10% attrition rate, a total of 55 participants were estimated per group.

$$\:n=\frac{{\left({z}_{\left(1-\alpha\:/2\right)}+{z}_{\left(1-\beta\:\right)}\right)}^{2}\left({\sigma\:}_{1}^{2}+{\sigma\:}_{2}^{2}\right)}{{\left({\mu\:}_{1}-{\mu\:}_{2}\right)}^{2}}=\frac{{\left(1.96+1.04\right)}^{2}\left({18}^{2}+{32}^{2}\right)}{{\left(128-108\right)}^{2}}=30.33\:\frac{{\left(1.96+1.04\right)}^{2}\left({5.4}^{2}+{3.7}^{2}\right)}{{\left(58.7-61.5\right)}^{2}}=49.19$$

,

,$\:\frac{{\left(1.96+1.04\right)}^{2}\left({5.4}^{2}+{4.2}^{2}\right)}{{\left(79.6-75.6\right)}^{2}}=26.3$

The primary investigator visited each comprehensive health service center, identified eligible individuals, and assigned them to either the intervention or control group via an allocation sequence hidden in opaque envelopes. The participants were assigned to groups according to the order in which they entered the study. Allocation sequence concealment was achieved via 110 numbered opaque envelopes, each containing a unique allocation sequence. To ensure a balanced allocation of participants to both groups and to accommodate the gradual enrolment of elderly individuals, a block randomization procedure with a block size of 4 was employed. The random allocation sequence was generated in collaboration with a methodological consultant.

Owing to the nature of the study, it was not possible to blind the participants. Prior to the intervention and prior to the allocation of participants to groups, questionnaires were completed by an individual who was unaware of group allocation. After the intervention, the same individual, who was blind to group allocation, completed the questionnaires. (Fig. 1).

Intervention

Prior to random allocation, all participants provided informed consent (written and verbal) and completed baseline assessments, including demographic data and questionnaires on ABCs, elderly self-care, and WHO-5 well-being. The participants were subsequently randomly assigned to either the intervention group or the control group. The control group received routine care and counselling from comprehensive health service centers. The intervention group underwent an individual empowerment program based on the 5A model, which, considering previous studies (22, 23, 27), was implemented over a 12-week period. After the 12-week intervention, the ABCs, elderly self-care, and WHO-5 well-being questionnaires were completed again by both groups through self-reports. The 5A model consists of five stages: Assess, Advise, Agree, Assist, and Arrange (25). (Table 1) (Fig. 2).

The first and second stages of the 5A model were conducted in the first session, individually and in person, lasting 60–75 minutes. The third stage was implemented individually during the second session via a 15- to 30-minute telephone call. The second session was held three days after the first session. The first three stages were carried out during the initial week. The fourth stage was conducted in person as a 90-minute group session during the third session in the second week. At this stage, individuals with similar problems are grouped together. The fifth stage (follow-up) was conducted via telephone calls from the third to the twelfth week. Follow-up was conducted three times a week during the first two weeks, twice a week during the second two weeks, and once a week thereafter. In-person sessions were held in a classroom setting at comprehensive health service centers, whereas remote sessions were conducted via telephone.

Table 1

stages of 5A model
Stages of 5A model	Sessions	Goals	Duration	Session content
The first two stages (assess and advice)	The first session	Assess: Evaluation of behavioral health risks and identification of patient problems. Advice: Providing information about the benefits of behavior change.	From 60 to 75 minutes	In the first stage, a comprehensive review of the patient's medical history was conducted, including a falls history, family history, body mass index, medication use, diet, sleep patterns, comorbidities, activity level, social engagement, symptoms, risk factors. Questionnaires and assessment forms were used to gather this information. In the second stage, patients were individually informed about the abnormal findings and problems identified in the initial stage, along with the benefits of behavior change. Information regarding the consequences and complications of, the fear of falling, falls, and the benefits of falls prevention behaviors and self-care activities was conveyed to the elderly participants.
The third stage (agree)	The second session	Agreeing on specific goals and an operational plan for behavior change.	From 15 to 30 minutes	In collaboration with the older adults, an operational plan was designed based on the problems identified in the first stage, taking into account the individual's goals and willingness to change behaviors and reduce challenges. To ensure adherence to the agreed-upon program, the elderly were asked to self-report their functional status on a weekly basis for each of the designated activities and report these findings to the researcher during follow-up.
The fourth stage (assist)	The third session	Assisting the patient in identifying barriers and developing strategies for overcoming them and develop an action plan.	90 minutes	In this session, training on fear of falling and falls was provided based on a booklet developed using guidelines from the WHO and other relevant articles and papers on fear of falling and falls. The content validity of the booklet was confirmed by relevant professors at Shahroud University of Medical Sciences. During the session, the elderly participants received training on falls prevention strategies, the nature, causes, consequences, and risk factors associated with falls and fear of falling, as well as simple balance exercises. Additionally, the participants received education on self-care, including physical self-care practices such as adhering to medication and dietary regimens, maintaining personal hygiene, engaging in regular physical activity, and ensuring sufficient sleep and rest. The training utilized a variety of methods, including lectures, question-and-answer, and the distribution of informational materials such as booklets and pamphlets.
The fifth stage (arrange)	Sessions 4 to 19 (During weeks 3 to 12)	Follow-up to review the agreed-upon plan and reinforce previous education and steps.	Each session lasts 15 to 30 minutes	At this stage, the previous four stages, the agreed-upon program, and the training provided in the fourth stage were reviewed with the elderly to reinforce motivation, recall the intervention, and ensure adherence. Operational plans requiring modification were revised, and any additional training needs expressed by the participant were addressed.

Data collection

The data collection instruments used in this study included a demographic form, the Activities-Specific Balance Confidence scale to measure falls self-efficacy, the Elderly Self-Care Questionnaire, and the WHO-5 Well-Being Index to assess quality of life.

The demographic data included age, weight, height, gender, marital status, occupation, fall history, education, number of drugs consumed, social activity, and history of chronic diseases.

The activity-specific balance confidence (ABC) scale was initially developed by Powell and Myers in 1995 to assess confidence in maintaining balance among older adults (10). The ABCs is a 16-item scale. Each item is rated on a 100-point scale, with 0 indicating no confidence and 100 indicating complete confidence (8). The maximum possible score is 1600, and the minimum is zero. To calculate an individual's score, the sum of their scores on all the items is divided by 16. The participants were asked to select a percentage to indicate their level of confidence in performing the activity without losing balance or experiencing instability (8, 10). A score of 67 or higher indicates greater confidence in performing specific activities related to falling, whereas a score below 67 suggests lower confidence (8, 10). In Powell and Myers' study examining convergent validity, the ABCs demonstrated a strong positive correlation with the physical activity subscale (r = .63, p < .001) and a moderate positive correlation with the physical self-efficacy scale (r = .49, p < .001). This study demonstrated good construct validity among the elderly population. Cronbach's alpha was .96, indicating high internal consistency of the ABC scale. Furthermore, the total ABC score exhibited high stability over a two-week period (r = .92, p < .001) (10). In the study by Hassan et al., Persian translation and cultural adaptation were conducted according to the International Quality of Life Assessment (IQOLA) protocol. Two proficient translators, unfamiliar with the questionnaire, independently translated the original English version of the ABC scale into Persian. The resulting version was then provided to two other translators, who independently rated the quality of the Persian translation on a scale of 0–100. The final translation was given to two more proficient translators who back-translated the scale into English. The English translation obtained from this stage, along with the Persian translation and the original version, was presented to 12 experts in the field of balance, who evaluated the quality of the translation and its cultural adaptation. To assess the facial validity of the Persian version of the scale, the instrument was administered to 10 elderly individuals representative of the study population. Reliability in this study was confirmed via a Cronbach's alpha coefficient of 0.96 and an ICC of 0.97 (30).

The Self-Care Questionnaire for the Elderly (in Persian) was designed and psychometrically tested by MaslakPak and Hashemloo in 2015. This questionnaire consists of 40 items scored on a 4-point Likert scale (often, sometimes, rarely, never). For positive statements, a score of 1 indicates 'never', and a score of 4 indicates 'often'. Conversely, for negative statements, a score of 1 indicates 'often', and a score of 4 indicates 'never'. The minimum score on this questionnaire was 40, and the maximum score was 160. A higher score indicates a greater level of self-care ability. This questionnaire assesses physical, daily, emotional, social, and illness-related self-care dimensions in elderly people. The face, content, and construct validity of this questionnaire were confirmed in MaslakPak's study. Specifically, the construct validity was supported by the confirmation of a five-factor structure. The content validity of this questionnaire was assessed on the basis of the judgments of experts in instrument design and other relevant fields and the Lawshe table and the content validity index of Waltz and Bales. A content validity index (CVI) score exceeding 0.79 was deemed appropriate for the acceptance of items. To assess the facial validity of the instrument, ten elderly individuals were recruited and asked to provide feedback on the ease of completing the questionnaire, the grammar and spelling of the words, and the clarity of the item wording. Construct validity was assessed via factor analysis. The results of the Kaiser‒Meyer‒Olkin measure (KMO = 0.777) and Bartlett’s test (p < .001) indicated that the factor analysis model was appropriate. The questionnaire demonstrated high internal consistency, with a Cronbach's alpha coefficient of 0/864 (31).

The WHO-5 Well-Being Index was developed in 1998 to measure positive well-being over the past two weeks (32). This questionnaire consists of 5 items and employs a 6-point Likert scale for scoring. The response options range from 'At no time' (scored 0) to 'All of the time' (scored 5), with intermediate options including 'Some of the time', 'Less than half the time', 'More than half the time', and 'Most of the time'. The minimum possible score is 0, indicating the absence of well-being, whereas the maximum score is 25, indicating optimal well-being. Higher scores are indicative of greater well-being, whereas lower scores suggest depressive tendencies. To convert the score range to a 0-100 scale, the raw score can be multiplied by 4 (33, 34). In the study by Eser et al., the construct validity of the questionnaire was demonstrated by its ability to differentiate between various demographic groups. The questionnaire was able to discriminate between individuals on the basis of age, gender, education level, income, and marital status. Education level and income emerged as the strongest differentiating variables (32). Furthermore, in this study, the Cronbach's alpha coefficient was reported to be 0.81 for adults and 0.86 for elderly individuals, indicating good internal consistency of the questionnaire (32). In the study by Dehshiri and Mousavi, the construct validity of the Persian version of this questionnaire was confirmed with a single-factor structure. The factor loadings of the items ranged from 0.79–0.87, indicating a suitable level. In this study, the internal consistency reliability of the questionnaire was assessed via the internal consistency method. The item‒total correlations ranged from 0.53 to 0.77, with a mean of 0.63, and Cronbach's alpha was found to be 0.89 (33).

Data analysis

Data were analyzed via descriptive statistics (means, standard deviations, frequencies, and percentages). Chi-square or Fisher's exact tests were used to compare qualitative variables (frequencies or percentages), whereas independent t-test were used to compare the means of quantitative variables between the control and intervention groups. An independent t-test was used to examine the effect of the intervention on changes in fall self-efficacy scores and other outcomes. Covariance analysis was used to assess the intervention effect, controlling for education level.

This study was conducted with the approval of the esteemed Research Deputy and Research Ethics Committee of Shahroud University of Medical Sciences (Ethics Code: IR.SHMU.REC.1402.137) and with permission from the esteemed officials of the research setting (Deputy of Health and Research, Golestan University of Medical Sciences) in the comprehensive health service centers of the city of Gorgan.

The mean and standard deviation of age were 68.32±3.39 years and 68.23±2.89 years, respectively, in the control and intervention groups. Prior to intervention, an independent samples t-test revealed no significant difference between the two groups (p=0.880). In addition, there were no significant differences between the two groups in terms of gender, marital status, history of falls, social activity status, job, and chronic diseases (hypertension, diabetes, visual impairment, hypothyroidism, and hypercholesterolemia), as determined by chi-square and Fisher's exact tests (p>0.05). Before the intervention, independent t-tests revealed no significant differences between the control and intervention groups in terms of the number of medications, weight, and height (p>0.05). However, a significant difference in education level was found between the two groups (p=0.027) (Table 2).

There was no significant difference in the mean fall self-efficacy scores between the two groups before the intervention (p=0.264). Similarly, no significant difference was observed between the two groups after the intervention (p=0.240), whereas the mean differences in the fall self-efficacy scores before and after the intervention was significantly different between the two groups (p<0.001). Before the intervention, there was a significant difference (p=0.009) in the mean self-care scores between the two groups. This significant difference persisted between the two groups even after the intervention (p<0.001), whereas the mean differences in the self-care scores before and after the intervention was significantly different between the two groups (p<0.001). There was no significant difference in the mean quality of life scores between the two groups before the intervention (p=0.469). A significant difference was observed between the two groups after the intervention (p=0.001). Additionally, the mean differences in the quality of life scores before and after the intervention was significantly different between the two groups (p<0.001) (Table 3).

The effect of the intervention, after controlling for the effect of education level, was examined via analysis of covariance. This analysis revealed that education level had no effect on the outcomes. After controlling for the effects of education level, there were significant differences (p<0.001) in the mean scores of fall self-efficacy, self-care, and quality of life between the control and intervention groups (post-intervention) (Table 4).

Table 3 compares the mean scores of outcomes (falls self-efficacy, self-care, and quality of life) before and after the intervention, and compares the differences in scores before and after the intervention between the two groups.
Falls self-efficacy (ABCs)	Mean ± Standard deviation		P value based on independent t test
Falls self-efficacy (ABCs)	Control group	Intervention group	P value based on independent t test
Before the intervention	71.46±8.93	69.46±9.76	P=0.264
After the intervention	71.98±8.75	73.95±8.64	P=0.240
Differences in scores before and after the intervention	0.52±0.97	4.48±2.29	P<0.001
Self-care(elderly self-care)
Before the intervention	136.83±7.54	133.47±5.65	P=0.009
After the intervention	137.41±7.16	144.10±6.84	P<0.001
Differences in scores before and after the intervention	0.58±2.73	10.63±4.34	P<0.001
Quality of life (WHO-5 Well-being)
Before the intervention	63.12±7.54	61.52±9.81	P=0.469
After the intervention	61.74±12.66	69.81±12.64	P=0.001
Differences in scores before and after the intervention	- 1.38±6.21	8.29±10.17	P<0.001

Table 4 Results of covariance analysis in determining the effect of intervention on the outcomes of fall self-efficacy, self-care, and quality of life after controlling for education level.
Falls self-efficacy (ABCs)	Mean square	F-statistic	p value
Falls self-efficacy before the intervention	7274.19	2935.89	P<0.001
Education level	2.16	0.87	P=0.352
group	396.96	148.11	P<0.001
Elderly self-care
Self-care before the intervention	3845.38	296.20	P<0.001
Education level	1.86	0.14	P=0.705
group	2354.03	181.33	P<0.001
Quality of life (WHO-5 Well-being)
Quality of life before the intervention	620.04	145.05	P<0.001
Education level	2.42	0.56	P=0.453
group	152.57	35.73	P<0.001

Despite extensive studies applying the model, no previous studies have examined the effects of empowerment, utilizing the 5A model, on fall self-efficacy, self-care, and quality of life among older adults. This study is one of the most recent in this field. This study aimed to determine the effect of empowerment via the 5A model on fall self-efficacy, self-care, and quality of life in older adults. The findings of this study revealed that empowerment led to improvements in fall self-efficacy, self-care, and quality of life among the study participants.

This research on empowerment via the 5A model revealed a significant positive effect on participants' self-efficacy related to balance during movement tasks. The results of the present study are consistent with the findings of SadeghiGolafshani et al. (2020), who reported that 5A self-management model-based education can increase self-efficacy among elderly diabetic patients (26). Amiri et al. (2022) demonstrated that a self-management program had a positive effect on self-efficacy among stroke patients. Findings revealed that, immediately and three months post-intervention, the mean self-efficacy scores in the intervention group significantly increased compared with those in the control group (27). In line with these findings, the study by Moradi et al. (2019) demonstrated that a self-management program based on the 5A model was effective in enhancing self-efficacy among older adults with hypertension. The study revealed a significantly greater mean difference in self-efficacy before and after intervention in the intervention group than in the control group (35). These studies are consistent with the findings of the present study. Furthermore, these studies share similarities with the present study in terms of the type of intervention employed. These studies differ from the present study in terms of the educational content provided. According to previous studies, improving fall self-efficacy can lead to a reduction in the fear of falling (8, 9). As FOF can lead to decreased self-confidence, loss of balance, and reduced social participation, it may contribute to a decline in elderly individuals' independence (7). Therefore, one of the primary goals of reducing the fear of falling is to promote healthy and active ageing. In line with this, a study by Chegini et al. (2022) demonstrated that educational interventions can enhance fall prevention knowledge and self-efficacy in hospitalized patients (36). Salbech et al. (2005) reported that task-oriented walking retraining can increase balance self-efficacy in community-dwelling individuals with chronic stroke (37). The results of the study by Dadgari et al. (2022) indicated that the discharge planning program was effective in reducing recurrent falls and the severity of injuries sustained in subsequent falls (38). These three studies are consistent with the results of the present study but differ in terms of the intervention used. While Arai et al.'s (2007) study did not demonstrate an effect of a short-term exercise intervention on fall self-efficacy among older adults, a potential reason for this lack of efficacy may be the participants' high baseline fear of falling scores. However, given the intervention's impact on other outcomes, it may be effective for individuals with lower baseline fear of falling scores (39). Garcia et al. (2012) reported that a fall prevention education program increased awareness of fall risk but did not significantly enhance the self-efficacy of older adults with respect to fall prevention. The second part of their results was not consistent with those of the present study. The disparate results between this study and the present study may be attributable to the 7-week intervention period and the small sample size of their study (40). Furthermore, these two studies differ from the present study in terms of the type of intervention.

On the basis of the results of the present study, empowerment, according to the 5A model, had a significant effect on self-care outcomes during the study period. Furthermore, the findings of Khoshkhoo et al. (2021) indicated that a trial based on the 5A model could lead to improvements in self-care and quality of life among elderly individuals with hypertension. The mean scores of self-care and quality of life significantly increased in the intervention group compared with those in the control group following the intervention (41). Asgharian et al. (2022) reported that implementing a 5A self-management program significantly impacted self-care and quality of life in elderly individuals with hypertension. The changes in the mean self-care and quality of life scores from pre- to post-intervention differed significantly between the control and intervention groups (28). The findings of one study demonstrated that the implementation of the 5A self-management program can increase the empowerment of elderly individuals with diabetes (22). While these three studies differ in terms of the instructional content provided, their findings are consistent with those of the present study.

According to the findings of the present study, the intervention based on the 5A model had a significant effect on quality of life. In line with these findings, Keyvan et al. (2023) reported that a 5A nursing model-based intervention significantly enhanced the quality of life of hemodialysis patients. Post-intervention analysis revealed notable differences in both specific and general quality-of-life domains between the intervention and control groups (23). A study by Rokni et al. (2022) demonstrated that diabetes self-management education based on the 5A model significantly improved the quality of life of women with gestational diabetes mellitus. Specifically, after the intervention, the quality of life of the intervention group was significantly greater than that of the control group (42). In line with these findings, Zhu et al. (2020) demonstrated that the 5A nursing model can enhance postsurgical quality of life in patients with cervical carcinoma (43). Zhang et al. (2021) demonstrated that 5A nursing intervention can increase the living quality of patients undergoing chemotherapy after hepatocellular carcinoma surgery (44). A study by Araby et al. (2024) demonstrated that the implementation of a strategy based on the 5A model resulted in an improved quality of life for patients with polycystic ovary syndrome (45). The findings of the five aforementioned studies are consistent with the results of the present study. While Javanoush et al. (2018) did not demonstrate the effect of a 5A self-management program on the quality of life of elderly patients with acute coronary syndrome during the study period, the results of the present study are inconsistent with these findings. Patient hospitalization and the duration of the intervention could be potential reasons for the discrepancy between the two studies (29).

Appropriate interventions that promote the empowerment of older adults can contribute to improving fall self-efficacy, self-care, and quality of life among elderly individuals. The 5A model positions the elderly individual at the center of managing their health conditions, fostering active participation in their treatment and self-care (22, 25). The implementation of the 5A model is both cost-effective and leads to a reduction in patient visits to clinics and hospitals, which can subsequently decrease healthcare costs (26, 28). The participants' problems were identified on the basis of the 5A model. Subsequently, tailored activity programs were designed for each individual. In the fourth step, educational sessions were conducted on falls, fear of falling, and self-care during old age. In accordance with the follow-up phase, the individuals' activity plans were reviewed, and their needs were addressed.

Limitations

This research has both strengths and limitations. The strengths of this study include its multicenter design, the selection of community-dwelling participants, and repeated follow-ups throughout the study. Despite the intriguing findings of this study, it has a limitation. Owing to the length of the intervention, full adherence by the elderly participants could not be guaranteed. However, through consistent follow-up according to the 5A model, this study achieved maximum adherence.

The results of the present study demonstrated that empowerment based on the 5A model significantly improved fall self-efficacy, self-care, and quality of life among community-dwelling older adults. On the basis of the findings of the present study, it is recommended that nurses and other healthcare providers utilize the 5A model to increase fall self-efficacy (reducing fear of falling and its associated complications), improve self-care behaviors in community-dwelling and hospitalized older adults, and ultimately enhance the quality of life of older adults in pursuit of achieving and maintaining active aging. Furthermore, the 5A model can be utilized in the realms of policymaking, implementation, and the design of care programs. Additionally, further research should be conducted into innovative empowerment interventions to ameliorate other challenges and issues related to aging.

ABCs: Activities-Specific Balance Confidence Scale

FOF: Fear Of Falling

MMSE: Mini Mental State Examination

ADL: Activities of daily living

Acknowledgements

The current research was approved by the research board of shahroud university of medical sciences (referral code: 200174). We gratefully acknowledge the collaboration of the Research Deputy of Shahroud and Golestan University of Medical Sciences, the heads of Gorgan’s comprehensive health service centers, and all the study participants.

Ethics approval and consent to participate

This study was approved by the Ethics Committee of Shahroud University of Medical Sciences (Ethics Code: IR.SHMU.REC.1402.137). Informed consent was obtained from all participants. The principles outlined in the Declaration of Helsinki (2013) were followed throughout the research.

Consent for publication

Not applicable

Availability of data and materials

The datasets used and analyzed during the current study are available from the corresponding author upon reasonable request.

Competing interests

The authors declare that they have no competing interests.

Funding

The author(s) disclosed receipt of the following financial support for the research, authorship, and/or publication of this article.

Authors' contributions

Ermia Maghsoodloo (EM), Hossein Ebrahimi (HE), and Ali Dadgari (AD) conceptualized the study. EM, HE, AD, Shahrbanoo Goli (SG) and Homeira Khoddam (HK) participated in the implementation of the study and writing the manuscript. EM and SG performed the analysis. The author(s) read and approved the final manuscript.

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Table 2 is available in the Supplementary Files section.

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Table2ComparisonofDemographicCharacteristicsBetweentheControlandinterventionGroups.docx

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The Effect of Empowerment Based on 5A Model on Fall Self-Efficacy, Self-Care and Quality of Life in Older Adults: A Parallel Randomized Clinical Trial

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