Falls Prevention in Community-dwelling Elderly in Brazil: Strategies and Difficulties in Primary Health Care

. The ageing world population has inspired the current care model to incorporate health promotion. The health of the elderly within primary health care aims to maintain functionality in old age. Thus, the prevention of falls by the elderly ensures health promotion by preventing various damages and health problems. Though, effective preventive action is a complex task that health workers have to face. It aims to highlight the difficulties encountered and describe the strategies used to achieve health promotion in the elderly to prevent falls. This is a qualitative research with Hegelian dialectics based on the methodological approach. The Focus group technique was made with community health agents from a municipality in the state of São Paulo, Brazil. The Content Thematic Analysis was used to process verbal discourses and retrieve in its entirety factors from data to classify and categorize all aspects of fall prevention. Findings point to difficulties related to the personal beliefs of the elderly, the difficulty of adapting to daily activities, and deficiencies in social support. Among the strategies adopted were multi-professional teams, family and social networks, and longitudinal approaches. The elements and factors described should be incorporated into primary care by health professionals, especially the nurse as a care manager, to encourage protective attitudes, behaviours, and activities with the elderly to maintain healthy ageing. Any related aspect can be partially or totally generalized, in different socioeconomic statuses, because they reflect daily life and potentially explain the incidence of falls under multidimensional issues.


Introduction
Healthy ageing is currently recognized as well-being in old age through the maintenance of daily, mental and social activities according to the experiences and resources of the elderly in their psychosocial sphere.Although it is perpetrated by the health-disease dichotomy arising from the physiological process of ageing, it is influenced by the person's trajectory and life-long health and social behaviours (Abud et al., 2022).
A preventive measure would be one that prevents damages, health problems, and diseases from occurring, or even worsens already existing dysfunctions.In order to prevent health-related problems at various levels, protective health behaviours must be performed intentionally by the individual.Promoting healthy practices, adopting healthy habits, and preserving risk factors can have consequences on the health and chronic disease processes as well as on the quality of life of individuals (Shada, Wong, & White, 2020).
Preventive and health promotion actions are crucial in the performance of primary health care for the elderly, to endorse integral care.In Brazil, several struggles led to profound structural changes in the health system in the 1980s and after experiences with a community orientation, it was established the "Family Health Program" in 1994 andlater denominated "Family Health Strategy" in 2006.The goal of primary care is to transpose the biomedical model while adding to the actions of diagnosis and treatment, promotion of health, family and community orientation, coordination of all patient care, accessibility, and intervening on psychosocial and environmental conditions by the health-disease process under the archetype of the functionality to age group using a multidisciplinary professional team in which nurse is a crucial role, the management of care.Through it, care is guided to maintain their physical and mental skills, and their autonomy and independence are conditioned by it (Medeiros, Pinto Junior, Bousquat, & Medina, 2017;Pinto & Giovanella, 2018).
Acta Scientiarum.Health Sciences, v. 46, e64932, 2024 In health care for the elderly, the prevention of falls is fundamental in ensuring health promotion.Falls represent an important public health problem in this age range, due to their significant incidence and damage to health such as fractures, depression, fear of falling, hospitalization, institutionalization, and mortality (Montero-Odasso et al., 2021).
Falls result from a complex interaction between individual risk factors and extrinsic factors, including environmental and behavioural factors, that have relevance to their incidence in the elderly in the community.These factors which are directly influenced by the wider context of the life of the elderly person should be part of the set of actions that encompass the integral health promotion and protection offered by primary care (Pohl et al., 2015;Robson, Coyle, & Pope, 2018).
So then, the objective of this research is to highlight the difficulties and strategies in primary care for the adoption of preventive behaviours for falls by the elderly in the community of Brazil.

Materials and methods
It is a qualitative study.This approach allows a dynamic investigation exposes the abstract framework that explains and comprehends a phenomenon from those who experience it, from those perspectives and understanding of aspects behind human actions.Qualitative research is composed of a variety of methods and techniques that express the diversity of the world´s vision.Furthermore, in the field of primary care, qualitative research has provided expressive interpretation and aid in different stages that quantitative studies could not supply (Bradbury-Jones et al., 2017;Hayashi, Abib, Hoppen, & Wolff, 2021).
The use of Hegelian Dialectics as a methodological approach is an accurate perspective for questioning and describing a complex problem.This theoretical reference from the philosophy is based on the "thesisantithesis-synthesis" form, which highlights the contradictory nature of the reality, the importance of the particular environment, and the context implicates the assistance in health (Fagerström & Bergbom, 2010).
Community Health Agents (CHA) are health workers that are inserted in community everyday life, subjects that are inside the universe in which the phenomenon of fall begins.By engageing in active observation, all aspects of ageing, as well as subjectivity and objectivity surrounding falls, can be expanded.A purposeful sample was chosen based on the inclusion criteria of primary care employees with more than three years of experience as Community Health Agents in a large municipality in the interior of São Paulo, with a proportionally high number of elderly residents.
Data collection was done through the Focal Group technique.By creating an open discussion and exchange of experiences, this analysis explores problematization of the theme, as well as participants' conceptions and stimulates opinions and attitudes (Kinalski et al., 2017).
Authors invited participants to participate, and there were no refusals.To facilitate participation, the meeting was held during working hours in a proper and appropriate space within the unit following the signing of the Agents' Free and Informed Consent Term.A 90 minute meeting was held in October 2017 and concluded when the CHA considered that all aspects had been addressed.
In this dialogue, community agents were allowed to present their perspectives as health workers and expose their daily difficulties in fall prevention.As the subject was approached, questions were generated as a semi-structured guide.'Proportionally, how many elderly adults are in your adscript territory?Have they fallen?Have you been doing fall prevention interventions?How do the elderly respond to fall prevention?What factors or aspects promote falls and how do you work on it?'.To achieve this deepening and expression of each element, the meeting was held with a minimum of five individuals and led by a coordinator with a doctorate in geriatrics, familiar to workers and experienced in the technique.Another author, trained in the technique, recorded impressions, non-verbal communication, and informal conversations in a field diary.
The meeting was fully recorded and transcribed for accuracy using the software Microsoft Office Word®.The lines were identified by the numerical sequence of the CHA speech.
The content thematic analysis technique was used since it is appropriate to explore and report many aspects of an issue found in data, for it seeks an understanding of social events and their origins, values, and behaviours.That consists of three steps: The first is the pre-analysis that includes superficial reading to familiarization, in which the rule of exhaustiveness was used to reach the assumptions of what the collected data would reveal and the organization of the skeleton.The second, called material exploration, is where the text is reread, reviewed, and extracted into thematic nuclei of meaning.The registration units were grouped into context units and categorized according to semantic criteria, meeting the homogeneity, relevance, and objectivity of each ordered set.The third is the interpretation of the results.This is a reflexive exercise, attempts to comprehend subjective or implicit meaning under the actions or experiences described.Furthermore, the elaboration of the analytical composition was outlined with the theoretical framework.Then, the findings understood in categories were compared to the literature to support, explain or clash (Minayo, 2014;Cardoso, Oliveira, & Ghelli, 2021).
To assure quality, the study has been developed with clarity, procedural rigour, and contemplative theoretic methodological approach.Besides, the data analysis was validated in tier triangulation by another researcher (Hayashi et al., 2021).
The research was previously approved by the Health Department of the city and by the Research Ethics Committee of the Ribeirão Preto Nursing College, University of São Paulo, CAAE: 68815317.3.0000.5393,according to the guidelines and norms for research with human beings by Resolution no.466/2012 of National Health Council, Brazil.Also, there was approval in prior contact with the unit coordinator after exposure to the research project and request for authorization.

Results and discussion
A characterization of CHA shows that all are females between the ages of 38 and 56.Their experience in the occupation ranges from five to 17 years.Four of them have completed high school and one has an incomplete higher education.In terms of their area of study, all said the unit offered training in geriatrics, including sexuality in old age, falls, vulnerability, and violence.
Data analysis brought the following thematic categories according to the fundamental dialectics method that seeks to expose contradictions and subjectivity of the phenomenon, the thesis, and the antithesis.For this purpose, the discussion´s categories contain two thematic categories and are subdivided: 1 -The difficulty and the subcomponents: fall and beliefs; everyday life adaptation; deficiency of social support; and, 2 -Strategies and the subcomponents: family and social network; multi-professional team; longitudinal.

Falls and beliefs
As a result of beliefs and pejorative portrayals about ageing, feelings arise such as the denial of old age, ashamed of becoming elderly, and fear of vulnerability in old age (Pereles, Jackson, Rosenal, & Nixon, 2017;Stevens, Sleet, & Rubenstein, 2018): "I think that the elderly don't want to be seen as disabled" (A5)."They're worried about others opinions.Maybe they want it, but not in front of others….."(A1).
The adoption of fall prevention becomes difficult because it requires behaviours that symbolize the acceptance of vulnerability, loss of autonomy, and physical vitality (Gardiner et al., 2017).Ratifying, the CHA portray the use of walking aids that they associate with these feelings and beliefs and is referred to as one of the most difficult activities to accept: "Why be ashamed to walk with a walking stick, explain it to me? See the other guy uses it.I think he feels limited.Wow, I'm getting old" (A3).Another participant (A4) said: "They have great difficulty in accepting the walking stick.Even if the doctor says it is good and helps, they have great resistance.What will they say about me?They have many... they have many falls in the street.But if you get the group and suddenly say: if you take the group and suddenly say: we are going to talk about elderly people falling!Ah excuse me, I'm leaving... I'm not interested.""They don't even pay attention."(A3).
Thus, the adoption of protective factors concerns the life experience and subjectivities to which identity and beliefs belong.These are built collectively, with symbolic, social, and psychological perspectives on old age and permeate the appreciation that the individual imputes to health, well-being, the role it plays and therefore influences the health behaviours adopted for active and healthy ageing (Teh, Brown, & Bryant, 2019).
Primary health care should include and integrate cultural beliefs and models about ageing in the elderly.It must be recognized that these affect health outcomes, prevention programs, health promotion activities, and provide resource efficiency (Mariño, 2015).
The implications for the end of life do not occur easily and bring under each individual their own way of coping.Many elderly people don't think about ageing in order to avoid suffering regarding the finitude of life.Health concerns are observed, but they do not become aware of them.It is emphasized that this stigma at this stage of life, denominating ageism, must be discussed so that life in its entirety is planned, without stereotypes, and fully enjoyed.It is known that ageism influences the elder´s well-being and adherence to prevention behaviours (Mari, Alves, Aerts, & Camara, 2016; Flores-Sandoval & Kinsella, 2020).

Everyday life adaptation
For the adoption of preventive behaviours in falls, the elderly are required to adapt to the physical conditions now imposed.This is especially painful to dialogue and work with, but necessary within comprehensive primary care assistance.How can be perceived in CHA speech: "There is this lady, she doesn't stop.She is very old, but very active.I always go by and ask her how she is, right?'Oh dear, I fell down" (A5)."…They think everything has to be their way" (A4).
Current models in the development of healthy ageing enhance health promotion, confirming its definition.It has involved and encouraged beliefs about the autonomy, participation, and self-care of the elderly for prevention, making care management more adaptive and related to positive behaviours (Mariño, 2015;Tavares et al., 2017).
There are many precautions elderly people can take to prevent falls without requiring very large adjustments.Daily activities should balance the risk of falling and the ability of preventive actions.This consensus should be understood and brokered between the primary care team, the elderly, and their families (Pohl et al., 2015).
Healthy ageing is due to the ability to self-care and adapt to life within physical, cognitive, and social limitations.Learning to cope with chronic illness, pain, disability and staying active, independent, and autonomous is the key to this ageing (Abud et al., 2022).

Social support deficiency
Social support includes various types of support: instrumental assistance in daily activities, assessment support or decision-making or problem-solving assistance, counselling information or particular needs, emotional support with the provision of care, affection, understanding, and value recognition (World Health Organization, 2015).
There is great heterogeneity in the elderly group in terms of housing, socioeconomic conditions, health conditions, quality of life, and social support, which suggests differentiated and adapted demands from primary care (Park, Ville, Schwinghamer, & Melgar-Quiñonez, 2019).
In this health unit, the speech below presents a picture of loneliness and abandonment as the most common portrait detected in the community: "Like most of the agents in the area, we encounter many elderly people.I've met a lot of elderly people who live alone and some don't have any support from their family.Either because the family didn't want to, doesn't want this contact with the elderly or the elderly person themselves don't want it.They prefer to have their own little place, to stay there on their own.And I have met many elderly people in this situation... of not wanting contact with the family" (A5).
The lack of social support highlighted here permeates the perception of the elderly about people who provide perceived support in a structural and solid form of help, and care.This absence and loneliness are common in old age and associated with widowhood, depression, lack of satisfactory relationships, physical inactivity, impaired autonomy, mortality associated with the incidence of falls, fear of falling, and the severity of consequences (Rantakokko et al., 2014).

Family and social network
Among the needs that fall prevention requires is a social network, not only as a promoter of psychological and emotional support at this stage of life.But it also helps to prevent actions that may compromise the safety of the elderly and risky behaviour actions.The importance of social relations and mental status is as significant in the health of the elderly as the physical conditions are highlighted.A social network is capable of promoting or maintaining emotionally and functionally the mental and physical state (Pereira, Santos, Moura, Pereira, & Landim, 2016).
"We try to provide guidance to the elderly.That's what I do, we try to talk to a... a relative or someone who is close, or who we have... when we have the possibility to meet; A relative, a married son, a daughter, a grandson.We have to raise awareness among the children or those who are close to them, the younger ones" (A1).
The strengthening of social support, as described above, is one of the strategies used by agents through the involvement of close and significant relatives to the elderly to prevent falls.Health behaviours and fall prevention are influenced by interpersonal relationships, whether formal or informal (Stevens et al., 2018).
Acta Scientiarum.Health Sciences, v. 46, e64932, 2024 One feature highlighted in the health unit was the use of elderly groups as an alternative to favour the active participation of the elderly.The participation of the elderly in social groups, operating groups, and physical activity groups, among others, has the purpose of valuing positive experiences and promoting active ageing."Inside of the groups, we work a lot of these things" (A2).
The positive attitude resulting from these activities is related to greater involvement and promotion of the elderly person's bio-psychosocial well-being and benefits education and prevention.Indirectly, these include increasing self-esteem, fighting loneliness, dialogue, finding solutions to common problems, and sharing information among peers.Furthermore, the exchange of experiences and support within the creation of bonds of belonging allows the broad growth or maintenance of the cognitive and functional faculties of the elderly (Pohl et al., 2015;World Health Organization, 2019).
These may provide better acceptance of health conditions and sustained maintenance of the proposed prevention or treatment; in other words, the greater the support network and social integration, the greater the degree of satisfaction and the greater the quality of life, resulting in a healthy ageing process (Giardini, Maffoni, Kardas, & Costa, 2018).
Thus, in primary care, holistic involvement with individuals in their community is necessary, to provide opportunities and encourage the active participation of the elderly, the structuring of family contact, the strengthening of ties, and assisting family members and the elderly in accessing information and to the dialogue on ageing.

Multiprofessional team
"One of the easiest things that ever happened to me was...I go and talk.Then you take a different person.For example, a student or even another agent that sometimes you end up taking or a nurse... the person goes and says the same thing, and then they listen, understand?You are already tired of talking, but they don't listen.Then, if it is someone different, another moment, another professional... then the person listens" (A4).
One of the most reported strategies was the communication of information in protective behaviours that could be adopted by elderly people through other actors.The literature confirms the use of the multidisciplinary team for counselling and education in consultations and home visits, preparation and evaluation of care plans, integration of information and interventions provided aggregation of knowledge, greater adoption of preventive behaviours by the elderly, and providing comprehensive care that promotes greater effectiveness in preventing falls (Mckenzie et al., 2017).
"I got a cane for her, brought her one, and it was very interesting because it coincided with the boys (nursing students) who were visiting her.So .... they started to take her out to some places, to the ice cream parlour, to a walk, I don't know where.And so, from then on, she adhered well to the cane" (A2).
The bond of the elderly with the team is based on dialogue and the relationship of trust with the verbalization of feelings, beliefs, and difficulties.This provides personalized assistance, qualified listening, humanization of care, increased satisfaction, and improved adoption of preventive behaviours advised by staff, as well as staff understanding of motivations and barriers in adopting fall prevention (Pereles et al., 2017;Stevens et al., 2018).

Longitudinality
"It is just with time passing by, slowly.Sometimes there is something that you said a year ago and they get it and change it after.But this is a long-term thing" (A1)."Like Mrs Maria, for example, she was fine.She's been using a cane for so long!" (A1).The statements above are answers to the question in the focus group, which, in the opinion of the agents, was the determining factor for the elderly in the adoption of prevention aimed at changing harmful behaviours to health.
The concept of longitudinal care is a unique characteristic of primary care.As time passes on, it is what strengthens the relationship with the elderly, with the family, and with the community.This ensures the continuity of care for a patient.Through continuous care, trust, and responsibi lity in the professional-user relationship, and the provision of constant therapeutic guidelines, this program is effective in promoting preventive behaviour.The team has the opportunity to maintain continuous communication, an adequate health education gradually according to the limitations of the elderly and counselling at different times and situations, and evaluation of the unique interventions for each elderly (Arce & Sousa, 2014;Mari et al., 2016).

Implication and reflection for nursing practice
After all, the shift to adopting preventive behaviours is attributed to subjectivities that have been constructed throughout a history filled with cultural contexts, apprehended perceptions, intentions, and habits, and involve multiple actions within a process, not modifiable by simple information, order, or an event (Mendoza-Ruvalcaba & Arias-Merino, 2015).
By condensing the thematic categories presented above, the CHA speech portrays the priorities for the health of elderly adults aiming for active ageing and quality of life: maintaining functionality, minimizing chronic disease, and promoting social participation.The components cover all dimensions of life that influence health and fall incidence (Mendoza-Ruvalcaba & Arias-Merino, 2015;Flores-Sandoval & Kinsella, 2020).
Economic situation, physical environment, psychological and cultural aspects, the stigma of ageing, lifestyle, school level, and access to health services can be worked on for health promotion through multidisciplinary actions and primary health care protagonist role.However, social support deficiency, violence in the territory assigned, incomplete team, overload of work, lack of materials and equipment, insufficient infrastructure, lack of psychological support because of the inability to solve problems experienced, unsuitable informatics system and mobility barriers may be reasons that focus primary care actions on a reproduction of the biomedical model.These are possible reasons why health services rather employ ineffective models than apply a holistic approach in a sustainable way that uses all forms of cooperation between health services and the means available to the community (Jatobá et a., 2020;Kim et al., 2020).
The primary care team even in this challenging scenario, works and improves on clinical practice for chronic and acute diseases, interprofessional collaboration, and the fundamental action of health education for the elderly and community (Torrens et al., 2020).
Education is part of the core of primary care.Health workers must conduct education in the community, qualify actions performed and offer effective assistance to prevent falls and healthy ageing.Improving and reducing risks with health education is not easy.The aged may perceive fall prevention as a threat to their ability to fulfil their daily tasks or activities that they have always performed.Besides, modifying risky behaviours and maintaining motivation for protective attitudes and activities such as daily or weekly physical exercises are difficult (Anderson & Lane, 2020;Liddle et al., 2020).
The resulting synthesis of fall prevention reveals that the knowledge of difficulties and strategies by CHA perception can bring a transformation when an elderly person's life context is understood and remodelling the management of primary care to provide integral care, and the elements described could be considered in planning care.

Conclusion
Primary care teams face numerous challenges when it comes to implementing fall prevention strategies with community-dwelling elderly patients.Based on the findings of this research, the Family Health Strategy identified several difficulties related to social, cultural, historical, and personal aspects.Developing fall prevention strategies that incorporate factors that transcend a superficial biomedical model and require a deeper engagement of the multiprofessional team in all aspects of the elderly individual's care.