Injury

=Injury (Fall) = = = **FACILITATORS: Alyssa Bartok, Cindy Bellanger, Brooke Schultz**


 * **Contents**
 * Learner Objectives
 * Required Readings and Websites
 * Healthy People 2020 Objective
 * Related Epidemiological Data
 * Screening Guidelines and Assessment Parameters
 * Behavioral Intervention Recommendations
 * Discussion of Intervention Efficacy ||

Learner Objectives »

 * Analyze how strategies to prevent falls among older adults impact Healthy Peop le 2020 goals.
 * Use appropriate USPSTF screening recommendations for people at risk due to age and gender.
 * Identify predisposing risk factors and behavioral interventions to reduce fall risk.

 Recommended readings and Websites »

 * [[file:Evidence-Based Exercise Prescription.pdf]]
 * American Geriatrics Society
 * Healthy People 2020: Older Adults.
 * [|CDC: Focus on Preventing Falls].
 * [|USPSTF website to identify appropriate prevention interventions].
 * <span style="font-family: Verdana,Geneva,sans-serif; font-size: 110%;">[|Injury Prevention & Control:][| and Recreational Safety].
 * [|Falls, Injuries Due to Falls, and the Risk of Admission to a Nursing Home]
 * [[file:Multifactorial intervention to reduce falls.pdf]]
 * [[file:CDC_Guide-a.pdf]]
 * [[file:CDC_Falls_Compendium_lowres.pdf]]
 * <span style="font-family: Verdana,Geneva,sans-serif; font-size: 90%;">The video below is from a PT and talks about assessing the older adult for falls and ways to prevent falls.
 * media type="youtube" key="M3XWyoEUgdY" height="315" width="420"
 * <span style="font-family: Verdana,Geneva,sans-serif; font-size: 90%;">The video below discusses how much of a public health crisis falls are and a sucessful program to prevent falls.
 * <span style="font-family: Verdana,Geneva,sans-serif; font-size: 110%;">media type="youtube" key="JqQGjPOFio0" height="315" width="420"

<span style="color: #000099; font-family: Verdana,Geneva,sans-serif;">Healthy People 2020 Objective »
<span style="font-family: Verdana,Geneva,sans-serif; font-size: 110%;">The goal of Healthy People 2020 as related to older adults is to improve the health, function, and quality of life of older adults. The objective that would relate to this WIKI is to reduce the rate of emergency department visits due to falls among older adults (Healthy People, 2012).

<span style="color: #000099; font-family: Verdana,Geneva,sans-serif;">Related Epidemiological Data »
<span style="font-family: Verdana,Geneva,sans-serif; font-size: 110%;">Fall related injuries are more common among older adults and can cause pain, disability, loss of independence and premature death. One out of three adults age 65 and older falls each year and falls are the leading cause of injury death for the older adult (CDC, 2011). In 2008, more than 19,700 older adults died from fall injuries and in 2009, 2.2 million nonfatal fall injuries among older adults were seen in emergency departments, of those 581,000 resulted in hospitalization (CDC, 2011). Injuries from falls can include lacerations, fractures (hip, spine forearm) and head trauma. There were 281,000 hospitalizations for hip fractures in the older adult in 2007. One out of five patients die within a year after a hip fracture and one in four adults must reside in a nursing home for a year or more after a hip fracture (CDC, 2011). A fall with or without injury can decrease the older adults quality of life due to fear of falling, this fear can cause the older adult to limit their activities.

<span style="font-family: Verdana,Geneva,sans-serif; font-size: 110%;">The risk of falling increases with age, a person 85 years old or older has a risk four times greater than a person age 65-74 years old of falling (CDC, 2011). Older women versus older men are at increased risk for fall injury. Older women have more than twice as many fall related fractures than men and in 2009, women were 58% more likely to have a nonfatal fall injury (CDC, 2011). Women account for most all hip fractures, with Caucasian women having significantly higher rates than African American women (CDC, 2011). The rate of death from fall however is higher for men. In 2007 older men had 46% more deaths from falls than older women (CDC, 2011). Older whites and older non-Hispanics have more fatal falls than African Americans and Hispanics (CDC, 2011).

<span style="font-family: Verdana,Geneva,sans-serif; font-size: 110%;">Normal changes of aging, like poor eye sight can put the older adult at increased risk for falls. Illness and physical conditions can cause decreased strength and poor balance. Medication side effects can make the older adult unsteady on their feet. Poor lighting and throw rugs in the home are tripping hazards. All of these things can cause falls in the older adult, but falls are not a normal part of aging. Falls are a for the most part a preventable public health problem. Fall prevention strategies include screening for risk factors, strength and balance training, home safety evaluation, vision screening and medication review (Davison, Bond, Dawson, Steen & Kenny, 2005; Shubert, 2011).

<span style="font-family: Verdana,Geneva,sans-serif; font-size: 110%;">**Potential impact of falls and injury due to falls in the elderly**

<span style="font-family: Verdana,Geneva,sans-serif; font-size: 110%;">Since 2011 when the first of the Baby Boomers hit 65 years old, 20% of our nation's population will consist of older adults. Every 18 seconds, a person 65+ years old goes to the ER due to injuries after a fall. The community-dwelling older adult is at risk to fall in their home, especially in the bathroom, bedroom, and stairs. The amount of money spent on admissions to the ER and hospital is expected to double to ~$40 billion now that the Baby Boomers are starting to reach 65 years old. These injuries can result in a loss of independence, mobility, and an impaired ability to perform simple ADLs and IADLs, resulting in temporary and/or permanent placement in a skilled nursing facility. <span style="font-family: Verdana,Geneva,sans-serif; font-size: 110%;">**//__An older adult dies as a result of complications from a fall__//** __**//every 35 minutes//**__.



[[image:Elderly-falls2.jpg width="200" height="235"]][[image:images-2.jpeg width="177" height="228"]]

 * <span style="font-family: Verdana,Geneva,sans-serif; font-size: 120%;">The American Geriatric Society Clinical Practice Guideline: Prevention of falls in older persons (2010) recommends: **
 * 1) ==All older individuals should be asked if they have fallen (in the past year).==
 * 2) <span style="font-family: Verdana,Geneva,sans-serif; font-size: 110%;">An older person who reports a fall should be asked about the frequency and circumstances of the fall(s).
 * 3) <span style="font-family: Verdana,Geneva,sans-serif; font-size: 110%;">Older individuals should be asked if they experience difficulties with walking or balance.
 * 4) <span style="font-family: Verdana,Geneva,sans-serif; font-size: 110%;">Older persons who present for medical attention because of a fall, report recurrent falls in the past year, or report difficulties in walking or balance (with or without activity curtailment) should have a multifactorial fall risk assessment.
 * 5) <span style="font-family: Verdana,Geneva,sans-serif; font-size: 110%;">Older persons presenting with a single fall should be evaluated for gait and balance.
 * 6) <span style="font-family: Verdana,Geneva,sans-serif; font-size: 110%;">Older persons who have fallen should have an assessment of gait and balance using one of the available evaluations.
 * 7) <span style="font-family: Verdana,Geneva,sans-serif; font-size: 110%;">Older persons who cannot perform or perform poorly on a standardized gait and balance test should be given a multifactorial fall risk assessment.
 * 8) <span style="font-family: Verdana,Geneva,sans-serif; font-size: 110%;">Older persons who have difficulty or demonstrate unsteadiness during the evaluation of gait and balance require a multifactorial fall risk assessment.
 * 9) <span style="font-family: Verdana,Geneva,sans-serif; font-size: 110%;">Older persons reporting only a single fall and reporting or demonstrating no difficulty or unsteadiness during the evaluation of gait and balance do not require a fall risk assessment.
 * 10) <span style="font-family: Verdana,Geneva,sans-serif; font-size: 110%;">The multifactorial fall risk assessment should be performed by a clinician (or clinicians) with appropriate skills and training.

<span style="font-family: Verdana,Geneva,sans-serif; font-size: 110%;">//Focused History// <span style="font-family: Verdana,Geneva,sans-serif; font-size: 110%;">//Physical Examinations// <span style="font-family: Verdana,Geneva,sans-serif; font-size: 110%;">//Functional Assessment// <span style="font-family: Verdana,Geneva,sans-serif; font-size: 110%;">//Environmental Assessment//
 * <span style="font-family: Verdana,Geneva,sans-serif; font-size: 110%;"> The multifactorial fall risk assess ****<span style="font-family: Verdana,Geneva,sans-serif; font-size: 110%;">ment should include the following: **
 * 1) <span style="font-family: Verdana,Geneva,sans-serif; font-size: 110%;">History of falls: Detailed description of the circumstances of the fall(s), frequency, symptoms at time of fall, injuries, other consequences
 * 2) <span style="font-family: Verdana,Geneva,sans-serif; font-size: 110%;">Medication review: All prescribed and over-the-counter medications with dosages
 * 3) <span style="font-family: Verdana,Geneva,sans-serif; font-size: 110%;">History of relevant risk factors: Acute or chronic medical problems, (e.g., osteoporosis, urinary incontinence, cardiovascular disease)
 * 1) <span style="font-family: Verdana,Geneva,sans-serif; font-size: 110%;">Detailed assessment of gait, balance, and mobility levels and lower extremity joint function
 * 2) <span style="font-family: Verdana,Geneva,sans-serif; font-size: 110%;">Neurological function: Cognitive evaluation, lower extremity peripheral nerves, proprioception, reflexes, tests of cortical, extrapyramidal and cerebellar function
 * 3) <span style="font-family: Verdana,Geneva,sans-serif; font-size: 110%;">Muscle strength (lower extremities)
 * 4) <span style="font-family: Verdana,Geneva,sans-serif; font-size: 110%;">Cardiovascular status: Heart rate and rhythm, postural pulse, blood pressure, and, if appropriate, heart rate and blood pressure responses to carotid sinus stimulation
 * 5) <span style="font-family: Verdana,Geneva,sans-serif; font-size: 110%;">Assessment of visual acuity
 * 6) <span style="font-family: Verdana,Geneva,sans-serif; font-size: 110%;">Examination of the feet and footwear
 * 1) <span style="font-family: Verdana,Geneva,sans-serif; font-size: 110%;">Assessment of activities of daily living (ADL) skills including use of adaptive equipment and mobility aids, as appropriate
 * 2) <span style="font-family: Verdana,Geneva,sans-serif; font-size: 110%;">Assessment of the individual's perceived functional ability and fear related to falling (Assessment of current activity levels with attention to the extent to which concerns about falling are protective [i.e., appropriate given abilities] or contributing to deconditioning and/or compromised quality of life [i.e., individual is curtailing involvement in activities he or she is safely able to perform due to fear of falling])
 * 1) <span style="font-family: Verdana,Geneva,sans-serif; font-size: 110%;">Environmental assessment including home safety


 * <span style="font-family: Verdana,Geneva,sans-serif; font-size: 120%;">Fall Risk factors to assess (National Center for Injury Prevention and Control, 2008) are, **


 * 1) <span style="font-family: Verdana,Geneva,sans-serif; font-size: 110%;">Mobility problems due to muscle weakness or balance problems
 * 2) <span style="font-family: Verdana,Geneva,sans-serif; font-size: 110%;">Chronic health conditions such as stroke and arthritis
 * 3) <span style="font-family: Verdana,Geneva,sans-serif; font-size: 110%;">Vision changes and vision loss
 * 4) <span style="font-family: Verdana,Geneva,sans-serif; font-size: 110%;">Loss of sensation in feet
 * 5) <span style="font-family: Verdana,Geneva,sans-serif; font-size: 110%;">Inactivity
 * 6) <span style="font-family: Verdana,Geneva,sans-serif; font-size: 110%;">Medication side effects and/or interactions
 * 7) <span style="font-family: Verdana,Geneva,sans-serif; font-size: 110%;">Alcohol use
 * 8) <span style="font-family: Verdana,Geneva,sans-serif; font-size: 110%;">Home and environmental hazards (clutter, poor lighting, etc.)
 * 9) <span style="font-family: Verdana,Geneva,sans-serif; font-size: 110%;">Incorrect size, type, or use of assistive devices (walkers, cane, crutches, etc.)
 * 10) <span style="font-family: Verdana,Geneva,sans-serif; font-size: 110%;">Poorly designed public spaces

<span style="font-family: Verdana,Geneva,sans-serif; font-size: 130%;"><span style="font-family: Arial,Helvetica,sans-serif; font-size: 11pt;">One example of a fall risk assessment tool


 * <span style="font-family: Verdana,Geneva,sans-serif; font-size: 120%;">USPSTF Screening recommendations for women and men 65-100 related to fall risks include the following: **

<span style="font-family: Verdana,Geneva,sans-serif; font-size: 110%;">**Grade:** B <span style="font-family: Verdana,Geneva,sans-serif; font-size: 110%;">**Specific Recommendations:** <span style="font-family: Verdana,Geneva,sans-serif; font-size: 110%;">The U.S. Preventive Services Task Force (USPSTF) recommends screening and behavioral counseling interventions to reduce alcohol misuse by adults, including pregnant women, in primary care settings.

<span style="font-family: Verdana,Geneva,sans-serif; font-size: 110%;">**Grade:** B* <span style="font-family: Verdana,Geneva,sans-serif; font-size: 110%;">**Specific Recommendations:** <span style="font-family: Verdana,Geneva,sans-serif; font-size: 110%;">The USPSTF recommends screening for osteoporosis in women aged 65 years or older and in younger women whose fracture risk is equal to or greater than that of a 65-year-old white woman who has no additional risk factors.

<span style="font-family: Verdana,Geneva,sans-serif; font-size: 110%;">**Grade:** I* <span style="font-family: Verdana,Geneva,sans-serif; font-size: 110%;">**Specific Recommendations:** <span style="font-family: Verdana,Geneva,sans-serif; font-size: 110%;">The USPSTF concludes that the current evidence is insufficient to assess the balance of benefits and harms of screening for osteoporosis in men.

<span style="font-family: Verdana,Geneva,sans-serif; font-size: 110%;">**Grade:** I <span style="font-family: Verdana,Geneva,sans-serif; font-size: 110%;">**Specific Recommendations:** <span style="font-family: Verdana,Geneva,sans-serif; font-size: 110%;">The USPSTF concludes that the evidence is insufficient to recommend for or against behavioral counseling in primary care settings to promote physical activity.

<span style="font-family: Verdana,Geneva,sans-serif; font-size: 110%;">**Grade:** I* <span style="font-family: Verdana,Geneva,sans-serif; font-size: 110%;">**Specific Recommendations:** <span style="font-family: Verdana,Geneva,sans-serif; font-size: 110%;">The USPSTF concludes that the current evidence is insufficient to assess the balance of benefits and harms of screening for visual acuity for th <span style="font-family: Verdana,Geneva,sans-serif; font-size: 14px; line-height: 21px;">e improvement of outcomes in older adults.


 * <span style="font-family: Verdana,Geneva,sans-serif; font-size: 130%;">Immunization guidelines for adults 65 and older (CDC,2012): **
 * <span style="font-family: Verdana,Geneva,sans-serif; font-size: 110%;">Recommended for all >65 if no contraindications identified
 * <span style="font-family: Verdana,Geneva,sans-serif; font-size: 110%;">Td one dose every 10 years
 * <span style="font-family: Verdana,Geneva,sans-serif; font-size: 110%;">Influenza one dose annually
 * <span style="font-family: Verdana,Geneva,sans-serif; font-size: 110%;">Varicella two doses
 * <span style="font-family: Verdana,Geneva,sans-serif; font-size: 110%;">Zoster one dose
 * <span style="font-family: Verdana,Geneva,sans-serif; font-size: 110%;">Pneumococcal one dose
 * <span style="font-family: Verdana,Geneva,sans-serif; font-size: 110%;">Only recommended if some otherrisk factor is present (e.g. on the basis of medical, occupational, lifestyle, or other indications)
 * <span style="font-family: Verdana,Geneva,sans-serif; font-size: 110%;">MMR one dose
 * <span style="font-family: Verdana,Geneva,sans-serif; font-size: 110%;">Meningococcal one or more doses
 * <span style="font-family: Verdana,Geneva,sans-serif; font-size: 110%;">Hep A two doses
 * <span style="font-family: Verdana,Geneva,sans-serif; font-size: 110%;">Hep B three doses





<span style="color: #000099; font-family: Verdana,Geneva,sans-serif;">Behavioral Intervention Recommendations »
<span style="font-family: Verdana,Geneva,sans-serif; font-size: 130%;">CDC (2011) recommends the following interventions to prevent falls, <span style="font-family: Verdana,Geneva,sans-serif; font-size: 110%;">**Prevention tips** <span style="font-family: Verdana,Geneva,sans-serif; font-size: 110%;">** Steps for Home Safety ** <span style="font-family: Verdana,Geneva,sans-serif; font-size: 110%; line-height: 21px;">**Steps for Safety in the Bathroom**
 * <span style="font-family: Verdana,Geneva,sans-serif; font-size: 110%;">**Get some exercise**: Lack of exercise can lead to weak legs, and this increases the chance of falling. Exercise programs like Tai Chi can increase strength and improve balance, making falls less likely for aging adults.
 * <span style="font-family: Verdana,Geneva,sans-serif; font-size: 110%;">**Be mindful of medications:** Some medicines—or combinations of medicines— can have side effects like dizziness or drowsiness. This can make falls more likely. Having a doctor or pharmacist review all medications can help reduce the chance of risky side effects and drug interactions.
 * <span style="font-family: Verdana,Geneva,sans-serif; font-size: 110%;">**Keep their vision sharp:** Poor vision can make it harder to get around safely. To help make sure they're seeing clearly, older adults should have their eyes checked every year and wear glasses or contact lenses with the right prescription strength.
 * <span style="font-family: Verdana,Geneva,sans-serif; font-size: 110%;">**Eliminate hazards at home.** About half of all falls happen at home. A home safety check can help identify fall hazards that need to be removed or changed, like clutter and poor lighting.
 * <span style="font-family: Verdana,Geneva,sans-serif; font-size: 110%;">Remove things you can trip over (like papers, books, clothes, and shoes) from stairs and places where you walk.
 * <span style="font-family: Verdana,Geneva,sans-serif; font-size: 110%;">Remove small throw rugs or use double-sided tape to keep the rugs from slipping.
 * <span style="font-family: Verdana,Geneva,sans-serif; font-size: 110%;">Keep items you use often in cabinets you can reach easily without using a step stool.
 * <span style="font-family: Verdana,Geneva,sans-serif; font-size: 110%;">Improve the lighting in your home. As you get older, you need brighter lights to see well. Hang light-weight curtains or shades to reduce glare.
 * <span style="font-family: Verdana,Geneva,sans-serif; font-size: 110%;">Have handrails and lights put in on all staircases.
 * <span style="font-family: Verdana,Geneva,sans-serif; font-size: 110%;">Wear shoes both inside and outside the house. Avoid going barefoot or wearing slippers.
 * <span style="font-family: Verdana,Geneva,sans-serif; font-size: 110%; line-height: 21px;">Adding non-slip surfaces and grab bars inside and outside the tub or shower to reduce slips and falls.
 * <span style="font-family: Verdana,Geneva,sans-serif; font-size: 110%; line-height: 21px;">Installing grab bars next to the toilet for added support, if needed.

<span style="font-family: Verdana,Geneva,sans-serif; font-size: 110%;"> Healthy People 2020 list the evidenced-based community intervention from the Guide to Community Preventive Services: Behavioral and Social Approaches to Increase Physical Activity: Social Support Interventions in Community Settings. This intervention is listed under the topic of Older Adults. These social support interventions focus on changing physical activity behavior through building, strengthening, and maintaining social networks that provide supportive relationships for behavior change (e.g., setting up a buddy system, making contracts with others to complete specified levels of physical activity, or setting up walking groups or other groups to provide friendship and support).

<span style="color: #000000; font-family: Verdana,Geneva,sans-serif; font-size: 130%;">Summary of Task Force Recommendations & Findings <span style="color: #000000; font-family: Verdana,Geneva,sans-serif; font-size: 110%;">The Community Preventive Services Task Force recommends implementing efforts made in community settings to provide social support for increasing physical activity based on strong evidence of their effectiveness in increasing physical activity and improving physical fitness among adults.


 * <span style="color: #000000; font-family: Verdana,Geneva,sans-serif; font-size: 110%;">In all nine studies reviewed, social support interventions in community settings were effective in getting people to be more physically active, as measured by various indicators (e.g., blocks walked or flights of stairs climbed daily, frequency of attending exercise sessions, or minutes spent in physical activity).
 * <span style="color: #000000; font-family: Verdana,Geneva,sans-serif; font-size: 110%;">These interventions also improved participants’ fitness levels, lowered their percentage of body fat, increased their knowledge about exercise, and improved their confidence in their ability to exercise.
 * <span style="color: #000000; font-family: Verdana,Geneva,sans-serif; font-size: 110%;">Interventions included in the review involved either creating new social networks or working within existing networks in a social setting outside the family, such as in the workplace.
 * <span style="color: #000000; font-family: Verdana,Geneva,sans-serif; font-size: 110%;">These interventions were effective in various settings including communities, worksites, and universities, among men and women, adults of different ages, and both sedentary people and those who were already active.

<span style="color: #000000; font-family: Verdana,Geneva,sans-serif; font-size: 110%;">This intervention could be used by a provider to encourage the older adult to exercise, which is recommended by the CDC to prevent falls.

<span style="font-family: Verdana,Geneva,sans-serif; font-size: 130%;">These are some brochures that the CDC has on their website: <span style="font-family: Verdana,Geneva,sans-serif; font-size: 110%;">What You Can Do to Prevent Falls <span style="font-family: Verdana,Geneva,sans-serif; font-size: 110%;">[]

<span style="font-family: Verdana,Geneva,sans-serif; font-size: 110%;">Check for Safety: A Home Fall Prevention Checklist for Older Adults <span style="font-family: Verdana,Geneva,sans-serif; font-size: 110%;">[]

<span style="color: #000099; font-family: Verdana,Geneva,sans-serif;">Discussion of Intervention Efficacy
<span style="font-family: Verdana,Geneva,sans-serif; font-size: 110%;">Falls are not an inevitable result of aging. Reviews of fall intervention studies have established that prevention interventions can result in a reduction in falls. The effective interventions can be classified as exercise based, home modification, and multifaceted (CDC, 2010). One multifactorial risk reduction study published by the //New England Journal of Medicine// reported a reduction in the number of falls in one year from164 in the control group to 94 in the intervention group. In addition, the total number of hospital days incurred due to falls was 45 versus 60 in the intervention and control groups respectively. In another randomized controlled study published in //Age and Aging//, a multifactorial intervention resulted in 36% fewer falls and a reduction in the duration of hospital visits.

<span style="font-family: Verdana,Geneva,sans-serif; font-size: 110%;">The Task Force on Community Preventive Services recommendation of social support interventions in community settings to increase physical activity is strongly recommended. The task force states: These programs are strongly recommended because of their effectiveness in increasing physical activity (specifically the time spent exercising and frequency of exercise) and improving physical fitness among adults. Other positive effects include increases in muscular strength and flexibility and decreases in adiposity. No harms were reported.

<span style="font-family: Verdana,Geneva,sans-serif; font-size: 110%;">The American Geriatrics Society recommends several interventions for fall risk reduction utilizing the same rating scale as the USPSTF. The components most commonly included in efficacious interventions are:
 * <span style="font-family: Verdana,Geneva,sans-serif; font-size: 110%;">Adaptation or modification of home environment [A]
 * <span style="font-family: Verdana,Geneva,sans-serif; font-size: 110%;">Withdrawal or minimization of psychoactive medications [B]
 * <span style="font-family: Verdana,Geneva,sans-serif; font-size: 110%;">Withdrawal or minimization of other medications [C]
 * <span style="font-family: Verdana,Geneva,sans-serif; font-size: 110%;">Management of postural hypotension [C]
 * <span style="font-family: Verdana,Geneva,sans-serif; font-size: 110%;">Management of foot problems and footwear [C]
 * <span style="font-family: Verdana,Geneva,sans-serif; font-size: 110%;">Exercise, particularly balance, strength, and gait training [A]

<span style="font-family: Verdana,Geneva,sans-serif; font-size: 110%;">The CDC’s guide for developing community-based fall prevention programs (see link under readings) offers recommended approaches to evaluate fall prevention programs. “Evaluation should begin while the program is in the earliest development stages, not after the program is complete. Evaluation is an ongoing process that begins as soon as someone decides to develop and implement a program; it continues throughout the life of the program; and it ends with a final assessment of how well the program met or is meeting its goals.” This guide discusses four stages of program evaluation: formative evaluation, process evaluation, impact evaluation and outcome evaluation. Specific to process evaluation the guide recommends the following: <span style="font-family: Verdana,Geneva,sans-serif; font-size: 110%;">1. To record the number of contacts with program participants (e.g., number of people attending each exercise class). <span style="font-family: Verdana,Geneva,sans-serif; font-size: 110%;">2. To record the number of contacts with people outside the program (e.g., number of meetings with partners). <span style="font-family: Verdana,Geneva,sans-serif; font-size: 110%;">3. To record the number of items a program distributes or receives (e.g., brochures and fact sheets). <span style="color: #000000; font-family: Verdana,Geneva,sans-serif; font-size: 110%;">4. To measure changes in people’s knowledge, attitudes, beliefs, or behaviors by collecting the same information at the beginning and end of the program. <span style="color: #000000; font-family: Verdana,Geneva,sans-serif; font-size: 110%;">5. To estimate the amount spent on delivering your program.

=<span style="color: #0074bd; font-family: Arial,Helvetica,sans-serif; font-size: 18px;">Grade Definitions = <span style="background-color: #ffffff; color: #333333; font-family: Verdana,Geneva,sans-serif; font-size: 110%;">The United States Preventive Services Task Force (USPSTF) has updated its definitions of the grades it assigns to recommendations and now includes "suggestions for practice" associated with each grade. The USPSTF has also defined levels of certainty regarding net benefit. These definitions apply to USPSTF recommendations released after May 2007.

<span style="font-family: Verdana,Geneva,sans-serif; font-size: 110%;">__**Grade: A**__
<span style="font-family: Verdana,Geneva,sans-serif; font-size: 110%;">**Definition:** The USPSTF recommends the service. There is high certainty that the net benefit is substantial. <span style="font-family: Verdana,Geneva,sans-serif; font-size: 110%;">**Suggestion for Practice:** Offer or provide this service.

<span style="font-family: Verdana,Geneva,sans-serif; font-size: 110%;">__Grade: B__
<span style="font-family: Verdana,Geneva,sans-serif; font-size: 110%;">**Definition:** The USPSTF recommends the service. There is high certainty that the net benefit is moderate or there is moderate certainty that the net benefit is moderate to substantial. <span style="font-family: Verdana,Geneva,sans-serif; font-size: 110%;">**Suggestion for Practice:** Offer or provide this service.

<span style="font-family: Verdana,Geneva,sans-serif; font-size: 110%;">__Grade: C__
<span style="font-family: Verdana,Geneva,sans-serif; font-size: 110%;">**Definition:** USPSTF recommends against routinely providing the service. There may be considerations that support providing the service in an individual patient. There is at least moderate certainty that the net benefit is small. <span style="font-family: Verdana,Geneva,sans-serif; font-size: 110%;">**Suggestion for Practice:** Offer or provide this service only if other considerations support the offering or providing the service in an individual patient.

<span style="font-family: Verdana,Geneva,sans-serif; font-size: 110%;">__**Grade: D**__
<span style="font-family: Verdana,Geneva,sans-serif; font-size: 110%;">**Definition:** The USPSTF recommends against the service. There is moderate or high certainty that the service has no net benefit or that the harms outweigh the benefits. <span style="font-family: Verdana,Geneva,sans-serif; font-size: 110%;">**Suggestion for Practice:** Discourage the use of this service.

<span style="font-family: Verdana,Geneva,sans-serif; font-size: 110%;">__Grade: I__
<span style="font-family: Verdana,Geneva,sans-serif; font-size: 110%;">**Definition:** The USPSTF concludes that the current evidence is insufficient to assess the balance of benefits and harms of the service. Evidence is lacking, of poor quality, or conflicting, and the balance of benefits and harms cannot be determined. <span style="font-family: Verdana,Geneva,sans-serif; font-size: 110%;">**Suggestion for Practice:** Read the clinical considerations section of USPSTF Recommendation Statement. If the service is offered, patients should understand the uncertainty about the balance of benefits and harms.