Falls and related hip fractures in aging adults are a very serious health care issue. With changing demographics and longer life expectancy the worldwide incidence of hip fracture is predicted to rise to 2.6 million by 2025, and to 4.5 million by the year 2050.1 There is evidence that almost 40% of all hospital admissions for fractures are for hip fractures, and that 90% of hip fractures are due to a fall.2 Although surgery can repair or replace fractured hips, the mortality at 1 year ranges from 12% to 25%. Among patients surviving, less than 50% regain their pre-fracture levels of physical function.3
According to Irish Hospital In-Patient Enquiry data, a mean cost of hospitalization for hip fracture was €14,300 ($21,250) in 2002; total annual cost was €11 million ($16,350 million).4 For the United Kingdom the total annual cost of hip fracture to society was estimated to be approximately £700 million ($1.3 billion) in 2000; the cost of care for a single aging adult surviving hip fracture and spending a year in long stay residential care was estimated to be approximately £25,000 ($47,000).5 In the Report of the European Union Osteoporosis Consultation Panel from 2003, the total cost in Europe of caring for patients in the first year after a hip fracture was estimated to be €14.7 billion ($21.8 billion).6
Because prevention of hip fracture has the potential to decrease health care costs, methods aimed at prevention of hip fracture are of considerable interest. Medications to improve bone density and physical therapy programs to improve balance and postural control are frequently used to minimize risk of falls and fractures.7,8 One noninvasive preventative strategy is the wearing of hip protector underwear garments with sewn-in or removable pads located over the greater trochanter that will shunt or absorb the force of a fall. The pads are made from materials such as soft memory foam (energy absorbing pads), hard polypropylene plastic shells (energy shunting pads) or a combination of both (Figure 1).
A number of studies have examined the mechanism of hip fracture and the biomechanical performance properties of hip protectors.9–11 Derel et al12 developed an anatomical hip model to simulate impact load on the hip of a falling person wearing a hip protector. This model has been used for assessing mechanical performance of energy-shunting and energy-absorbing hip protectors. These authors stressed the importance of hip protector placement. A template for correct positioning of hip protectors has been developed by Minns et al.13 The mechanical efficacy of various hip protectors has also been evaluated; mechanical efficacy is the ability of the pad or protector to reduce force generated at impact below a bone fracture threshold.14,15 Despite differences in methods across studies, mechanical efficacy of hip protectors has been supported.14 Van Schoor et al compared 10 different hip protectors to determine differences in effectiveness between energy shunting (hard) and energy absorbing (soft) hip protectors.16 This work found that energy-shunting hip protectors are superior to the energy-absorbing samples in simulations of normal weight aging adults. Lewis evaluated 5 materials considered candidates for the padding of an external hip protector in terms of their energy return ability.17 This study indicated that increasing ethylene vinyl acetate (EVA) content results in improved performance of the material. Meyer et al demonstrated that hip protectors are protective of fracture from impact forces in a fall, and reduce the costs of fracture care.18 Kiel et al however question the efficacy of hip protectors.19 This study was terminated after a 20 month follow-up due to a lack of efficacy. This clinical trial of an energy absorbing 1-sided hip protector fail to detect protective effect on the risk of hip fracture as the incidence rate of hip fracture on protected vs. unprotected hips did not differ. A systematic review of the literature on the use of hip protectors by Parker et al concluded that effectiveness of hip protectors in reducing the incidence of hip fracture is unclear.20
Two issues cited in the literature as impacting efficacy of hip protectors in fracture prevention are patient/user compliance and lack of awareness or understanding.21–23 Cryer et al, described challenges persuading aging adults living in residential care homes to routinely wear hip protectors.24 In contrast, Burl and colleagues reported high compliance rate (more than 90%) in the at-risk long-term care population.25 Many authors have suggested that achieving high compliance requires an interdisciplinary approach.25–27
Most of the studies of compliance with hip protector use collected information from health providers or medical records, and from the aging adults to whom hip protectors were prescribed. Perceptions and characteristics of aging adults who decide to wear or not to wear hip protector garments are not well understood. The purpose of this descriptive study is to identify factors influencing low user compliance with hip protectors among aging adults at risk of falling and hip fracture. This was achieved through a questionnaire aimed at the aging adults themselves and at the health care professionals involved in the patient treatment. Better understanding of factors associated with low compliance may contribute to improvements in hip protector design, strategies for patient education, and overall use of hip protectors as a means of reducing risk of fracture in a vulnerable population.
For this descriptive study 2 questionnaires were developed in consultation with the medical personnel (including research nurse) at the Mid-Western Regional Hospital, Limerick Ireland and St. Camillus Hospital, Limerick Ireland. Ethics Approval was received from HSE Ethics Research Committee at Mid-Western Regional Hospital, Limerick and the University of Limerick.
One questionnaire was designed for use with communityliving aging adults with high risk of falling and hip fracture (Table 1, top). It was comprised of 26 multiple choice questions relating to the respondent's medical condition and perception of acceptability of hip protectors. A similar questionnaire intended for medical professionals (physicians, physiotherapists, occupational therapists, nurses, and caregivers) had 20 multiple choice questions relating to the professional's knowledge of hip protectors and their perception of patient responsiveness (Table 1, bottom). Each questionnaire included space for written comments that respondents should select to provide additional information. Respondents were allowed to choose more than one answer for each question.
A pool of 91 aging adults was identified based on medical history by the participating research nurse from the Day Hospital Unit (Out-Patient Service) in St. Camillus Hospital, Limerick, Ireland (74 potential respondents) and the Day Care Unit in Milford Care Centre, Castletroy, Co. Limerick, Ireland (17 potential respondents). Aging adults were considered to be at high risk of hip fracture if they were aged 60 years and over and were identified as having at least one of the following: diagnosis of osteoporosis, history of hip fracture, and/or at least one previous fall. All of those from St. Camillus Hospital had osteoporosis and considered at high risk of falling and hip fracture. Those from Milford Care Centre were considered at risk of fracture, but not all had diagnosis of osteoporosis.
Individual appointments were arranged for all aging adults who met inclusion criteria and agreed to participate. During this meeting respondents were provided with a description of the study's purpose and given an opportunity to ask questions, signed an informed consent form, and completed the questionnaire with the investigator's assistance. For those who wanted to participate but could not attend appointments, the study was explained in conversation by telephone. Once the signed informed consent was mailed and received, the questionnaire was administered by a subsequent phone call. All interviews were completed by a single researcher.
A meeting was held at each of the health care locations for the health professional who agreed to participate. After listening to an explanation of the study's purpose and methods and asking questions about the study, they provided informed consent and completed the questionnaire.
After all questionnaires were collected, the data was analysed using the Statistical Package for the Social Sciences programme (SPSS, SPSS. Inc, United States of America). For this descriptive study, frequency of responses to question options was determined.
Responses from Aging Adults
Seventy-four (81.3%) of 91 eligible respondents agreed to participate. Fifty-nine (79.7%) were from St Camillus Hospital and 15 (88.2%) were from Milford Care Centre. Ten of those eligible declined because of poor health; an additional 7 were unreachable by phone. Forty-nine face to face interviews and 25 phone interviews were completed.
Sixty-one (82.4%) of the 74 respondents reported history of osteoporosis, 15 (20.3%) had a previous hip fracture caused by a fall, and 1 (1.3%) reported an osteoporotic hip fracture. Almost 80% (58) of respondents had at least one previous fall. Forty-five (60%) reported fear of falling.
Fourteen (18.9%) of the 74 respondents currently used hip protectors, 9 (12.1%) wore hip protectors in the past but no longer did so, and 51 (69.0%) had never used hip protectors. Within the group of 51 aging adults who never used hip protectors, 47 (92.2%) were previously diagnosed with osteoporosis and received a recommendation to wear the protective garment. Fifty-five (92%) respondents who never or formerly wore hip protectors (n=60 or 74 total respondents) answered questions about reasons for not using hip protectors (Figure 2). The most common reason given for non-use was lack of information (26 of 55 respondents, 47.3%). Of respondents citing lack of information, most (18 of 26, 69.2%) were not at all aware of hip protectors; the remaining reported incomplete understanding (8; 30.8%) that made them reluctant to use them. Twelve of 55(21.8%) non- or former users reported that they did not need to use a hip protector for their medical condition. Eleven of these individuals (91.6%) did not report fear of falling. The high cost of the product and discomfort were cited by reasons for non use by 10 of 55 (18.2%) of non- and former users. Eight of 55 (14.5%) reported bulkiness of the garment and difficulty putting it on as reasons they would not consider wearing the hip protectors.
Among former users, 3 of 9 (33.3%) reported discontinuing hip protector use because their medical condition improved, and the device was no longer necessary. The remaining 6 former users (66.7%) cite discomfort when using hip protectors and difficulties with putting it on as the factors supporting the decision to stop wearing the protectors.
Seventeen of 23 (73.9%) respondents who were current (14) or former (9) hip protector users responded to questions about hip protector use (Figure 3). Nine of 17 (52.9%) reported that wearing hip protectors gave them extra confidence when walking. Eight of 17 (47.1%) reported that hip protectors were comfortable to wear, and 7 (41.2%) reported that wearing protectors was a good idea. There were also some strong negative opinions. Seven of 17 (41.2%) of former and current users found the protective device uncomfortable and couldn't agree with appearance with the product on while 5 of 17 (294%) stated that the hip protector was difficult to put on and also expensive.
In the health professional group, there was a potential pool of 74 respondents; 54 from St. Camillus Hospital and 20 from Milford Care Centre. All potential respondents must have documented involvement with patients at risk of falls and hip fracture. Thirty-nine (52.7%) of health professionals agreed to participate; 22 (40.7%) were from St Camillus Hospital and 17 (85.0%) from Milford Care Centre. The members of this group included 17 nurses, 12 physiotherapists, 6 occupational therapists, 3 care assistants, and 1 physiotherapy assistant.
The majority of health professional respondents (n=37 of 39, 94.6%) stated that they were aware of the purpose and use hip protectors; 25 of 37 (66.7%) reported knowledge of hip protectors and recommended them to their patients. Thirty-five (89.7%) reported their opinions about hip protectors (Figure 4). Most of these (24 of 35, 68.6%) reported that hip protectors were uncomfortable, difficult to put on, or resulted in an unacceptable appearance. Six of 35 (17.1%) described hip protectors as bulky, difficult to wash, and expensive. Four of 35 (11.4%) thought that hip protectors were hot and heavy to wear. Thirty-two respondents reported their patients' opinions about the device (Figure 5). Twenty-five of 32 (781%) reported that patients complained about lack of comfort with the device, 22 (68.8%) patients find hip protectors difficult to put on and 16 (50.0%) said that patients find the device expensive.
This study contributes to the literature on requirements and preferences of hip protectors adding the perspective of the aging adult to that of health professionals. Discussion with respondents including current and potential hip protector users helped identify key shortcomings of existing devices and brought a fresh insight into the needs and design preferences for new hip protection devices. Data from health professionals confirmed a very high level (approaching 95%) of awareness of hip protectors as a strategy for reduction of hip fracture risk, with two-thirds likely to recommend use of hip protectors to their patients who are at risk of hip fracture. Awareness of hip protectors was not as high (74.3%) among community living aging adults, with incomplete or missing information about their purpose and effectiveness cited as the major reason for not using them. There is an apparent difference in knowledge and understanding about the benefits of hip protector use between health professionals and the aging adults they care for in the facilities participating in this project. Some of patient-respondents may have been reluctant to provide their reason for choosing not wearing hip protectors (such as high cost of the product, its bulkiness, or continence and comfort issues) and so may have opted to endorse “lack of information” as an explanation. Comments about non-use from patient-respondents included reasons such as ‘no need to use hip protectors’ and that the ‘hip protector made the patient feel geriatric.’ Although the number of respondents endorsing this view is low, it may be that this perception is more widespread. Similar opinions were provided by some of health professional respondents, who stated that use of hip protectors created a negative geriatric image, and so was a clear barrier to use. While aging adults were more concerned about product appearance and cost, health professionals highlighted difficulties with correct management of the protective device.
The outcomes of this study agree with findings on compliance reported by Patel et al28 where presented reasons for not wearing hip protectors included lack of comfort, bulkiness, aesthetics, and difficulties with putting the hip protector in position. In addition to confirming many of Patel's findings, this study also provided new insights relating to user compliance. The high cost of the product appeared to be a major barrier to compliance for both current and non-user groups. These respondents were, however, positive about the protective device. Despite complaining about lack of comfort and high cost, more than half of current and former users feel more comfortable when wearing the device and stated that they would not go out without a hip protector in position. Moreover, nearly half of the respondents indicated freely that hip protectors are a valuable adjunct in fracture prevention. This is the first study to show that aging adults have a clear understanding of the positive benefit of hip protector devices. This new finding combined with all the clinical evidence of hip protector effectiveness reported by Lauritzen et al,29 Meyer et al,30 and Bentzen et al31 support the use of hip protectors for fracture prevention.
The descriptive component of this study brought a fresh insight into wide range of aspects of compliance with hip protectors. In contrast to previously completed studies in addition to establishing reasons for not wearing the hip protector devices current users' opinions and suggestions about the hip protectors were also collected and are presented. To complete the range of opinions, a group of medical professionals who were dealing with patients at high risk of hip fracture were asked for their personal opinions relating to hip protectors and to their patients experience with such devices. We believe that this could result in new perspectives in design and utilisation aspects of new hip protection devices. Some medical conditions typical for patients in the fracture risk group highlighted the importance of a simple and uncomplicated garment. Many elderly people have to deal with incontinence issues and frequent toileting. In addition to this, a majority of fragile elderly people suffer from osteoporosis, osteoarthritis, or rheumatism. As a consequence, every day tasks such as getting dressed become very difficult for this group and need to be taken into consideration with any new design.
There were no major difficulties with conducting the survey as it only involved filling out the questionnaire. However there were some limitations including the bias of collecting the data in the aging adults group and the main bias occurred with participants who agreed to be interviewed over the phone, as some seemed very confused. We feel that personal contact during the interview with all participants would improve the quality of data and this should be taken into consideration when future studies of this nature are being carried out. Furthermore, if the study was repeated, the authors would include larger population of community dwelling aging adults at high risk of hip fracture assessed through a more sophisticated screening program. For the current study aging adults were recruited based on guidance from the clinical professionals. The authors believe that in addition to guidance from the clinical professionals, further recruitment guidelines might include osteoporosis data, an assessment of risk of falling and an assessment of mental awareness of the aging adults. This would improve the profile of the study population. Additionally a future correlation study would take into consideration the possible relationship between variables that influence user compliance. This may involve cross tabulation between demographic data and hip protector awareness as well as particular factors of poor user compliance.
To supplement the view on hip protectors presented by its actual and potential users it is clear that there is also need for follow up, comprehensive, multi-centred, randomised clinical study. The focus of such a future study would be the generation of a stronger body of evidence to support the use of hip protectors by aging adults at risk of hip fracture.
Due to the low number of participants, this study should be classified as a pilot study. However the survey did provide an insight into clinical and subject preferences with hip protectors, and it was found that there is poor user compliance with the current protective devices (only 18.9%). This study has proven that aging adults with a risk of hip fracture, however concerned about their safety, are struggling to wear hip protectors for a few reasons. Many of the participants claim lack of information about hip protectors. For this reason, the authors believe that it would be desirable practice for physical therapists and others working with aging adults to introduce hip protectors and stress their importance in preventing hip fracture to patients at risk of falling and hip fracture. We believe that this would improve patient confidence and compliance with wearing hip protectors resulting in reduced hip fracture incidence.
The survey had also provided important empirical data for creation of a design brief for improved hip protectors. These designs will focus on the absorption and distribution of impact forces with the realistic limitations of the impact protection device while being both comfortable and affordable. Clearly future designs need to address user-friendly appearance of the product, simplicity in use and cost. All the opinions about existing hip protectors obtained from users and medical professionals are a valuable input for identifying new design features.
The authors thank the participants and staff at St. Camillus Hospital in Limerick Ireland and Milford Care Centre in Castletroy Ireland. Special thanks go to the Irish Research Council for Science, Engineering and Technology (IRCSET) and BeoCare Ltd. Killarney, Ireland for funding this project.
This work was supported by a Grant No. RS/BE006/01 from the Irish Research Council for Science, Engineering and Technology and was co-sponsored by Beocare Ltd, Killarney Ireland.
This study was conducted under Ethics Approvals: University of Limerick Research Ethics Committee- ULREC No. 07/27 and Ethics Research Committee at the Mid-Western Regional Hospital, HSE at 7/03/2007.
1. Gullberg B, Johnell O, Kenis JA. World-wide projections for hip fracture. Osteoporos Int.
2. Scott V. Presentation. Preventing hip fracture. BC Injury Research and Prevention Unit. Victoria, Canada.October 2002.
3. Magaziner J, Hawkes W, Hebel JR, et al. Recovery from hip fracture in eight areas of function J Gerontol.
4. Cotter PE, Timmons S, O'Connor M, Twomey C, O'Mahony D. The financial implications of falls in older people for an acute hospital. Ir J Med Sci.
6. Melton LJ 3rd, Gabriel SE, Crowson CS, Tosteson AN, Johnell O, Kanis JA. Cost-equivalence of different osteoporotic fractures. Osteoporos Int.
7. Deprez X, Fardellone P. Nonpharmacological prevention of osteoporotic fractures. Joint Bone Spine.
8. Siris ES. Patients with hip fracture: What can be improved? Bone.
9. Mills NJ. The biomechanics of hip protectors. Proc Instn Mech Engrs.
10. Robinovitch SN, Hayes WC. Prediction of femoral impact forces in falls on the hip. J Biomech Eng.
11. Robinovitch SN, Hayes WC. Energy-shunting hip padding system attenuates femoral impact force in a simulated fall. J Biomech Eng.
12. Derler S, Spierings AB, Schmitt K-U. Anatomical hip model for the mechanical testing of hip protectors. Med Eng Phys.
13. Minns RJ, Marsh A-M, Chuck A, Todd J. Are hip protectors correctly positioned in use? Age Ageing.
14. Kannus P, Parkkari J, Poutala J. Comparison of force attenuation properties of four different hip protectors under simulated falling conditions in the elderly: an in vitro biomechanical study. Bone.
15. Nabhani F, Bamford J. Mechanical testing of hip protectors. J Mater Proc Technol.
16. Van Schoor NM, Van der Veen AJ, Schaap LA, Smit TH, Lips P. Biomechanical comparison of hard and soft hip protectors and the influence of soft tissue. Bone.
17. Lewis G. Characterization of the Performance of External Hip Protector Materials. Biomedical Engineering Conference, 1996; Dayton, OH, USA.
18. Meyer G, Wegscheider K, Kersten JF, Icks A, Mühlhauser I. Increased use of hip protectors in nursing homes: economic analysis of a cluster randomized, controlled trial. JAGS.
19. Kiel DP, Magaziner J, Zimmerman S. et al., Efficacy of a hip protector to prevent hip fracture in nursing home residents. The HIP PRO Randomized Controlled Trial. JAMA
20. Parker MJ, Gillespie WJ, Gillespie LD. Hip protectors for preventing hip fractures in older people (Review). The Cochrane Collaboration.
21. Stokes EK, Bourke A, Monaghan F, Scully C. Hip protectors-A survey of practice in Ireland. Ir Med J.
22. Van Schoor NM, Smit JH, Twisk JW, Bouter LM, Lips P. Prevention of hip fractures by external hip protectors- a randomized controlled trial. JAMA.
23. Cameron ID, Cumming RG, Kurrle SE, et al. A randomised trial of hip protectos use by frail older women living in their own homes. Inj Prev.
24. Cryer C, Martin AK, Barlow J. Hip protector compliance among older people living in residential care homes. Inj Prev.
25. Burl J, Centola J, Bonner A, Burque C. Hip protector compliance: a 13-month study on factors and cost in a long term care facility. JAMD
26. Dunn KR, Brace CL, Masud T, Haslam RA, Morris RO. Prevention of fall-inducted hip fractures: usability evaluation of hip protectors. In: Contemporary Ergonomics 2005, ed. PB Bust and PT McCabe,
Ergonomics Society Conference, Hatfield, 6-8 April 2005: 464-468.
27. Thomson P, Jones C, Dawson A, Thomas P, Villar T. An inservice evaluation of hip protector use in residential homes. Age Ageing.
28. Patel S, Ogunremi L, Chinappen U. Acceptability and compliance with hip protectors in community-dwelling women at high risk of hip fracture. Rheumatology.
29. Lauritzen JB, Petersen MM, Lund B. Effect of external hip protectors on hip fractures. Lancet.
30. Meyer G, Warnke A, Mühlhauser I. Fall and fracture prevention in the elderly. Geriatr Aging
31. Bentzen H, Bergland A, Forsén L. Risk of hip fractures in soft protected, hard protected and unprotected falls. Inj Prev.
Keywords:Copyright © 2009 the Section on Geriatrics of the American Physical Therapy Association
hip protectors; fracture prevention; hip fracture