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Rural Health Information Hub

Reducing Rural Unintentional Injuries, with Amy Rosenfeld, Jessica Dayton, and Jane Strommen

Date: June 4, 2024
Duration: 46 minutes

Amy Rosenfeld Jessica Dayton Jane Strommen
An interview with Amy Rosenfeld, Senior Research Director of the NORC Walsh Center for Rural Health Analysis, Jessica Dayton, Executive Director of the Chautauqua Safety Village, and Jane Strommen, PhD, Gerontology Specialist at North Dakota State University. After providing an overview of unintentional injury programs, we discuss two regionally implemented examples.

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Organizations and resources mentioned in this episode:


Andrew Nelson: Welcome to Exploring Rural Health, a podcast from the Rural Health Information Hub. My name is Andrew Nelson. In this podcast, we'll be talking with a variety of experts about providing rural healthcare, problems they've encountered, and ways in which those problems can be solved.

June is National Safety Month, and today we're going to be examining some of the ways in which we can avoid or reduce the risk of unintentional injuries. Joining me to provide us with an overview of this topic is Amy Rosenfeld, Senior Research Director of the NORC Walsh Center for Rural Health Analysis. Thank you for joining me, Amy.

Amy Rosenfeld: It's nice to be here.

Andrew Nelson: You recently helped to develop a toolkit for RHIhub that deals with unintentional injuries. Why is this topic important for rural communities, and what are some examples of unintentional injuries we might see?

Amy Rosenfeld: Unintentional injury is one of the five leading causes of death in both urban and rural communities and the leading cause of non-fatal injury. So it's really an important topic. It has such a wide-reaching impact on all of our communities. It's also really important to think about is that these are all preventable injuries. So, there are proven interventions and strategies that can be implemented to prevent these injuries and deaths from ever happening. Why this topic is so important for our rural communities is that while deaths from these injuries have generally decreased over time, we still see differences and significant disparities in the outcomes for people who experience these types of injuries in rural settings versus our urban settings.

And so [it 's] just really an important public health issue for all rural communities to consider. And then in terms of examples of unintentional injuries — some of the ones that we cover in the toolkit — there's unintentional poisoning, which includes drug overdose, but also poisoning from ingesting other harmful substances, injuries from falls. Another big one is injuries that result from motor vehicle crashes — people in cars, but also ATVs or pedestrians on the street even. And we talk a bit about drowning injuries and injuries that result from fires.

Andrew Nelson: Gotcha. What differences have you seen in the occurrences or incidences of unintentional injuries in rural areas, as opposed to more urban areas?

Amy Rosenfeld: What we've seen in the data and the research is that the rates and outcomes from these injuries, specifically the death rates, can be vastly different based on location. We looked a lot at data and reports from the CDC [Centers for Disease Control and Prevention] and it shows that the rural death rate from unintentional injuries has at times been 50% greater in rural areas compared to urban. And we also see that certain populations and ages fare differently, so again, the outcomes from the injuries are very different. Children of all ages in rural areas are more likely to die from unintentional injuries than children in urban areas. Drowning deaths, for example, are higher in rural areas compared with urban communities.

There's lots of different reasons have been identified that kind of account for these differences and outcomes, factors like limited access to healthcare, lack of trauma care in some areas, having to travel further distances for care. And some of the occupations more common in rural areas can increase risks for injuries.

I know some of the reports from the CDC back to the 1980s, looking at trends in unintentional injury, some of the data has shown that some causes of preventable death in the U.S. and injuries have decreased. But I think since 2010 there has been a pretty significant increase in unintentional injuries and deaths from those injuries. But a lot of that they attribute to the epidemic and drug overdoses, because that's classified as poisoning. But also there's been increases in motor vehicle crashes and deaths from those crashes, and that's something that has changed over the years.

Andrew Nelson: What are some types of interventions that you found are effective in terms of reducing unintentional injuries in rural communities?

Amy Rosenfeld: There are many strategies that have proven effective at reducing the occurrence of unintentional injuries in rural communities. And we highlight a lot of different prevention practices in the toolkit. One section we start out with is, we focus on ways to prevent injuries and death from motor vehicle crashes. So many of these things are common strategies that we've heard have been effective for a long time. So things like using a seatbelt correctly, using child safety seats, decreasing impaired and distracted driving from being on the phone.

And then there are other traffic safety measures that communities have adopted and sort of new strategies and approaches, something called the Safe System Approach, which is a more holistic way to prevent crashes and make community-wide changes. We also know that certain programming communities — like having child safety seat distribution during different community events where families can receive car seats for free and education about how to install the seats properly — those types of practices have been really effective.

And then we also talk about falls prevention in the toolkit, and some of the approaches we highlight include different evidence- or exercise-based fall prevention programs. There's a program called Fit & Strong. There's another one called A Matter of Balance. And then there's many different in-home exercise programs, which all focus on building strength and balance and really improving coordination and to prevent falls. And also they usually have an educational component. And some of them do focus on home modifications as well. So there are different things that people can do to identify hazards in their home and make sure that they're getting rid of any of those.

There is a section on drowning prevention strategies. Some of the interventions there that have been proven really effective are pool fencing, using life jackets, education around boating safety, swimming lessons, and teaching CPR and different rescue techniques are all evidence-based and can prevent drownings from occurring.

Andrew Nelson: Can you tell us about some of the facilitators and barriers to unintentional injury prevention in rural areas?

Amy Rosenfeld: Some of the organizations we spoke with talked about having strong community leaders and partners; people that are recognized as change agents who can really advocate for these causes and people that are embedded in the community so they can educate about these issues. And then what else was really effective and I think can facilitate implementation of some of these programs is having a strong sense of community, a sense of place; people talked about having like a community gathering place where people can come together to learn about these issues. Because I think there is still a big need for education around some of these topics. And having community volunteers, or just organizations that can spread the word about this was really a key facilitator.

And then in terms of barriers, we also heard some of the more common challenges to implementing unintentional injury prevention in rural areas. You know, sometimes environmental factors can make it more challenging to address some of these issues. They see increased exposure to some environmental hazards and that can make certain injuries more common, depending on work activities and recreational activities. Challenges that people experience in rural areas can make the outcomes of these injuries more severe. So, factors like having to travel long distances to access healthcare services or long wait times for emergency responders to be able to get to people living far away from a trauma center, or having a lack of trauma care providers can all really impact the outcomes of people who experience unintentional injuries.

Andrew Nelson: Yeah, definitely. Later I'll be talking to Jessica Dayton with the Chautauqua Safety Village and Dr. Jane Strommen with North Dakota State University's implementation of the Stepping On program. What are some other noteworthy examples you've seen of education or resources for preventing unintentional injuries?

Amy Rosenfeld: In developing the toolkit, we heard so many great ways that communities are coming together to educate about injury prevention and what is working in different communities. There are many strategies that are being implemented and different resources that are being used to educate people about how to prevent specific types of injuries. I can just talk about a few of the organizations that we spoke with and some of the programming that they're implementing. So, in terms of thinking about preventing some of the common childhood injuries like injuries from motor vehicle crashes or bike and other traffic-related injuries, we spoke with the Benton Franklin Health District in Washington that works with Safe Kids Worldwide, which provides resources to coalitions to prevent these types of injuries.

In terms of drowning prevention, they've organized these life jacket loan boards that are located at different swimming and boating areas, so basically there's access at all times for people to have life jackets. And they also post water safety educational information at different locations. They also lead different programming around installing and using child safety seats correctly. They have trained technicians that can check and make sure that they're installed correctly. They put on events like bike rodeos, which are events that are organized in communities to educate children and their families about bicycle safety, how to wear helmets. And I think they give out free helmets at a lot of these events and have fittings.

And then we also heard from the Southcentral Foundation in Alaska who has partnered with other organizations to create an ATV [all-terrain vehicle] safety program. And they're also using this idea of bike rodeo, but for ATVs to teach about ATV safety, the importance of wearing helmets. And they are working with the national curriculum and they're working to train people in communities to be able to deliver this training on ATV safety.

One of the other programs we spoke with was the Upper Midwest Agricultural Safety and Health Center, UMASH. They're implementing a program called RF-DASH, which stands for Rural Firefighters Delivering Agricultural Safety and Health. And so they're training firefighters in different states to go to farms and educate agricultural workers about farm safety. And these firefighters, they're using trusted members of the community who are going to these different farms and conducting interactive training and providing resources and tools that workers can use to essentially assess their farm hazard risk. And then if they identify any risks, they come up with ways to mitigate them and just be better prepared in the case of an emergency. So that is just a few of the programs and resources we highlighted in the toolkit, but there are several other organizations we interviewed. And then lots of other helpful resources in there.

Andrew Nelson: It's really cool to hear about all of these great programs that specialize in providing education about different ways in which people can avoid unintentional injuries. What are some future possibilities for other ways in which we can continue that education?

Amy Rosenfeld: So, there are a lot of policy considerations and opportunities for further reduction of unintentional injuries that we found. There's definitely a need for increased awareness and more education around many of these topics, and education campaigns designed with the input of rural communities. And then for some of these areas with more research and focus on preventing injuries, we might see some of the strategies and recommendations change over time. So as an example, we talked a little bit about infant suffocation prevention from unsafe sleeping practices. We've seen the American Academy of Pediatrics over the years, they've updated their recommendations for infant sleep environments. And with that we've seen some regulations change around products that are marketed and different safety standards when these recommendations change.

We've seen a lot of strategies that individuals can adopt to reduce their own risk of unintentional injuries. But then there are some strategies that are more focused on holistic changes that can be made in communities that show a lot of promise for preventing injuries. So, one of the things we talked about in the toolkit about related to preventing motor vehicle crashes is this Safe System Approach, which is a broader holistic strategy for preventing injuries and deaths on roads that involves the input and buy-in of all community members. And so it involves safety measures for all road users, whether you're in the car or you're walking on the street. But it also involves infrastructure changes and system-wide changes, like changes to roads to make them safer and then even changes in the care that people receive after a crash, if they're in one. So I think there are many opportunities for thinking about unintentional injury prevention in a more holistic way, and for thinking about these broader systems changes in the future.

Andrew Nelson: I'm now talking to Jessica Dayton, executive director of the Chautauqua Safety Village. Thank you for joining us today, Jessica.

Jessica Dayton: Thank you so much for having me.

Andrew Nelson: Yeah, absolutely. To get started here, can you tell us what the Chautauqua Safety Village is and how it came to be?

Jessica Dayton: Absolutely. The Chautauqua Safety Village is a not-for-profit organization. We're located in Western New York, and we are the only hands-on safety training facility that's designed to simulate real-life situations as closely as possible to the real thing. We have a miniature village complete with paved roads, a traffic light, railroad crossing. And then we also have a mock apartment that has simulated smoke, a door that heats up to 105 degrees, a safety ladder that the kids go down. So, it's a very interactive state-of-the-art training facility. Safety Villages originated in Canada. And there were a couple of local groups that had toured the facility. They were our local American Legion and Sertoma Club. They had toured the facilities in the mid-90s out in Canada, and then they brought the idea back to the sheriff in our county and discussed the possibility of creating one here, just because it was so unique and different. And we ended up working for years to get enough sponsorship and support and funding to build the facility. From there, we opened in the fall of 2010.

Andrew Nelson: Cool. I understand that each building in the Village has a sponsor. How did you go about engaging with local communities to get the word out so that people could start benefiting from the Safety Village?

Jessica Dayton: When we were looking at building sponsors, it was a lot of grassroots efforts and joining community meetings and kind of hitting the ground running with a lot of those presentations for the community to take part in the Safety Village buildings that we have in our miniature village. And they would sponsor a building and then they would have the naming rights to that building if they supported it. Outside of the village buildings that we have, we try to do a lot of community outreach as much as we are able that we have capacity for.

Andrew Nelson: Sure. Can you tell me a little bit more about some of the different programs that you offer at the Village?

Jessica Dayton: When we started in 2010, we had three, and we've grown to thirteen in the last 14 years. So we were really almost adding a program a year, which was based on community need and request and what we saw had become issues here. So, our primary programs are our fire safety program and our traffic and bike safety programs. We combine that with kind of pedestrian and crosswalk safety. But then as we grew over the years, we added programs for older kids, teenagers, and adults. So, we provide CPR and AED [automated external defibrillator] training and certifications in our community now, distracted driving awareness programs for teenagers. We go into local schools, provide basic childcare and first aid programs. We have a five-hour babysitter training for kids between the ages of 12 and 16, first aid, and for the little guys, we do poison and gun safety. So we really provide programs between the pre-K, 4-year-old range, all the way through adulthood now.

Andrew Nelson: Wow. Yeah, that's quite a diverse array of programs that you're offering there. Of course, there are many different types of programs across the country that help to reduce the risk of unintentional injuries and things like that. What sets the Village apart from other unintentional injury prevention programs?

Jessica Dayton: The Safety Village and the concept of the Safety Village is all about offering hands-on and interactive experiences. So we teach the concepts to the participants regardless of their age, but then they get to practice in order to refine those skills. And that way, in the event an emergency does happen, participants will most likely remember the practice more than the concepts taught in a learning classroom setting. Even as an adult now, I remember experiences I had throughout my lifetime versus lessons taught through a classroom. I think what sets us apart is that we provide that immersive experience. For people of all ages in our community, we provide that hands-on interaction so that they can improve their muscle memory, so that they can recall those safety practices a little bit more acutely than when you learn in a classroom setting.

So for example, our certifications for CPR are through the American Heart Association, and those certifications last two years because nationally, there's been research that has suggested that you have to practice those skills to be able to retain that muscle memory of giving chest compressions and breaths and things like that. The strength of this approach is that our programs build on each other year after year, providing that retention of skill, physical skill, in some of those areas that people don't often practice, in a safe environment that gives them as close to real life as possible.

Quite a few years ago now, we had a 6-year-old girl named Madeline who had attended the Safety Village with her school on her in her first-grade year. Of course, while she was here, she learned all about fire safety and the importance of having a family fire escape plan at home. And kids are encouraged to create one with their families if they don't already have one in place. And Madeline had gone home and shared this with her family and shared the field trip that she had been on and how she had learned all these things. And the family ended up making their very own escape plan and emergency plan should a fire ever break out in their home. They learned two ways out of every room of their house. They had a meeting place, so they set it all up after her, her time with us here, and then just a few short months later, there was a fire that broke out in the middle of the night in their home. And they followed their escape plan to the T and were all able to make it out safely. All of the children and the parents got out unharmed. Their house was a total loss, but that was a direct correlation between what she learned here and actually going home and sharing that with her family. And it turned out to be something super impactful where it really benefited them just a few months later.

Andrew Nelson: Yeah, that's great. Literally lifesaving education. It 's got to feel very validating or very satisfying to know that you're having that kind of impact in people's lives.

Jessica Dayton: It absolutely does. It's one of those situations where you hope they never need it. But preparing and providing those learning opportunities to prepare them for the chance that this could happen is extremely important.

Andrew Nelson: Can you tell us about the importance of coalition-building or forming partnerships in order to increase your outreach and the effectiveness of your programs?

Jessica Dayton: Coalition-building and partnerships are essential to a program like this. Our organization is one that you come to and you see for your own self what is taking place. And then those people that observe this become your biggest ambassadors, they see the hands-on learning and the simulations that take place, they see the benefits that it's bringing the community. And so having a strong network of partners and coalition members is essential to the success of your program. They not only gain awareness, but they directly see the impact that it's having on the participants of the program as well. So, for us, having that support from our partners and from area community members and coalitions has really been a huge part of our success.

Andrew Nelson: Gotcha. And there are other Safety Villages around the country, right?

Jessica Dayton: Yes, there are. We are all independent of one another. It's not like we are a national organization, but we do try to get together via Zoom quarterly to kind of just update each other on best practices and what's happening across the country and to kind of stay in touch with one another and coordinate. But to our estimate, there's about 26 full facilities in the United States, and then there's a lot more in Canada as well throughout, throughout that country.

Andrew Nelson: Oh, that's really cool. Kind of a kind of a community of model communities.

Jessica Dayton: It is.

Andrew Nelson: What advice would you give to other communities that maybe don't have a Safety Village right now, but are interested in exploring that possibility or adopting this approach?

Jessica Dayton: Having gone through a lot of the process, I would say that you don't need a fully equipped facility to start providing hands-on training. And if you're able to prove that this hands-on training works, even if you're going into community organizations or providing sessions in a school and with that hands-on approach, that's going to go far in getting you supporters for the program. Even just something as simple as if you're teaching first aid and bringing supplies in, to actually have kids practice applying splints and pressure dressings and performing the Heimlich Maneuver, things like that. You don't have to have your own facility to get started. It's definitely something that you can start by providing that interactive experience no matter what your capacity is. And I think that's crucial. And then anybody that's interested in getting into a facility, you're going to start being able to show results from those hands-on trainings being provided, which will gain you support.

Andrew Nelson: Since you established the Village, have you noticed that there are any adjustments you've had to make in the way programs are set up or in the way you're providing instruction?

Jessica Dayton: Yes, we have had to alter just because we're constantly trying to enhance and improve our programs. And some of the differences from when we started is budgetary restrictions on transportation to the Safety Village. So we've made adjustments so that if you can't get to the Safety Village, we will come to you. We want to make sure that people use these programs as a tool, and if they can't come to our facility and practice hands-on, we will bring hands-on practice to them where they're at. So that's a big adjustment that we've made. And so now regularly we do go into schools — funding for field trips in our area seems to take place primarily in the elementary schools — so, a lot of our going into schools and community organizations tends to be middle and high school. And then community adults as well for CPR trainings, we will go on the road. So we don't just provide those trainings here.

Andrew Nelson: So, the Village refers to a physical location, but also to a construct of instructional programs that are kind of mutually complementary. And that instruction can be provided other places as well, not just at the physical Village.

Jessica Dayton: Yes, that's correct. And it entails a lot from us on our end because like in the summer especially, we will pack all our bikes into a trailer, and we will bring all of our bikes down to a facility or an organization and we will set up bike safety and do it there for them. So, you know, we bring those tools to them so that they can still have that experience.

Andrew Nelson: Looking to the future, are there any ways you have in mind in which you want to expand or transform or increase outreach to further educate people?

Jessica Dayton: Absolutely. Water safety is something that we do not currently provide, and we live close to a lake. And so there's been tragedies that have happened surrounding that. So we're looking for ways to be able to provide something along those lines. And then I think something else that's very important for us is that we would love to formally evaluate our programs. We are prevention-based, so if we do our job well, we might not necessarily hear of success stories that people use the skills they learned here and averted an emergency. So being able to officially, formally evaluate our programs would go a long way to knowing who has used that knowledge in unexpected or emergency situations.

Andrew Nelson: I'm talking now with Dr. Jane Strommen. Dr. Strommen is a gerontology specialist at North Dakota State University, and she also oversees the NDSU implementation of the Stepping On Program. Thank you for joining us today.

Jane Strommen: I'm glad to be with you.

Andrew Nelson: To get started here, can you tell us a little bit about what the Stepping On Program is, and how it got started?

Jane Strommen: Absolutely. Stepping On is an evidence-based fall prevention program. It's an education and exercise program. It is designed for older adults, and it addresses the many factors that play into fall risks for older adults, including things like medications that place you at a higher risk for falls, your physical fitness, primarily lower body extremity strength, and your balance is important. What vision changes does a person experience with the aging process that might lead you to cause more problems with falls? Our environment, our home, our yard, our environmental modifications that we need to do. Just navigating safely around in the community, having those good mobility strategies and many other things; choosing safe footwear. We look at calcium and vitamin D for bone health, and it's really a multi-factor education program that also includes strength and balance exercises that are led by a physical therapist.

Andrew Nelson: Sure. Aside from the obvious immediate risk of injury, what are some other possible complications or consequences that can result from a fall?

Jane Strommen: Well, there are a lot of consequences that can happen. Obviously if somebody has a bad fall, they can become fearful of another fall and sometimes limit their activities, which also can be a downward spiral for many people. If they do fall and get hurt, it might diminish their capacity just to do that. Their normal activities of daily living, getting around the house, grocery shopping, doing all of those types of things. Also the cost of a fall, whether you need to go to the emergency room, you need care, it ends up costing some money out of pocket or maybe even a short rehab stay at a long-term care facility; the pain involved with a fall. And then of course, the worst-case scenario is that a fall really has altered your ability to live independently at home and that you maybe need to move to a different setting. And so it can really be life-changing for some people.

Andrew Nelson: I can see how it's really important to just avoid it ever happening, if that's all possible. Because there are all sorts of complications that can come from that.

Jane Strommen: Absolutely.

Andrew Nelson: What are some ways in which fall prevention might be even more important in rural areas?

Jane Strommen: Well, in rural areas, a couple things that come to mind is that there are often less housing options for older adults in rural areas, and such as single-story homes that you could move into that might be easier to navigate as somebody's health declines. Many times, people end up aging in place in the home that they lived in for many years, and oftentimes these homes really become unsafe as somebody's health changes, or they have some chronic illnesses that develop; just the frailty of aging. So, falls can be a big concern for people living in housing that maybe isn't the best fit for them. And then if somebody does have a fall and it interferes with their ability to drive, driving is very essential for people living in rural areas. Oftentimes, they have to drive for just about everything. Oftentimes there isn't the medical providers and those types of services that they need right in their community. Or, even right in their community, there are limited transportation options if you can't drive yourself. So driving is kind of an essential factor if you're living in a rural area. And if you fall, you hurt your leg, hip, arm, shoulder, whatever, where you're not able to drive, it could really be a big challenge.

Andrew Nelson: If somebody wants to participate in a Stepping On course, what are the requirements?

Jane Strommen: It is designed for older adults. In North Dakota, we define that as 60 and over. The research was done on older adults. It's certainly helpful for people who have fallen in the past, or maybe they're fearful of falling and they're living in their home. They're living in the community.

We have class leaders or facilitators across the state that are delivering this program. And we have an evaluation at the end of the seven weeks, and then there's a three-month follow up session, they call a booster session. We have evaluations done at the end of seven weeks, at the end of the booster session. So we get to interact with these facilitators and they send us their evaluations, and we get to hear and read all about the great results that people are having. And from the participants, I think what we hear the most is, they've learned so much. They didn't know that they should talk to their pharmacist or doctor about medications that would place them at higher risk for falls. Or a really interesting one — they didn't realize how important your strength training was, your strength and your balance was for falls. That is a key component. If you start losing that strength and balance, that it just places you at such high risk for falls. So there are so many things that participants have shared with us that they didn't realize those connections between falls. But I think the greatest thing hearing from, just overall from participants is that they just feel more confident, they feel stronger, and they feel more confident that they can live at home and not be fearful that they're going to slip or fall. And that quality of life, that's really important. The other thing that we do, when we we're looking at evaluations, we want to make sure we know it's an effective program. It's evidence-based, but I mean, we get the results.

People are talking about after three months, they come back and they say 72% are still exercising routinely. They're doing those exercises. 97% had assessed their home environment for fall hazards or safety hazards. 90% had considered safe features when choosing their footwear, when they're going out and about things like that. The evaluation results have been just so strongly positive that we know that this program is really working for older adults.

Andrew Nelson: It's got to be really encouraging to hear back from people how helpful that is. Given that this is a national program, are there any challenges you've had to overcome or adjustments that you've made to provide this instruction to people in North Dakota?

Jane Strommen: The program first started in North Dakota in 2013, and it was actually the North Dakota Department of Health then who had received a grant and was able to bring in some trainers from the Wisconsin Institute for Healthy Aging, which is a national license holder. They came in, trained a group of us, and then since then we've been able to train our own leaders in North Dakota. But we had a nice group of trained facilitators, and then COVID hit and programs like this, across the nation, all halted because older adults were that vulnerable group. And so, the program was halted for a year and a half at least. And one of the requirements being evidence-based is all the facilitators needed to be retrained, which was another two and a half, three-day commitment.

And we had a lot of public health nurses and home healthcare nurses that were busy giving vaccines at the time and couldn't get retrained. So, we kind of had a retrenching time where we had to start over; we had to train people again. And so, the program has been rebuilding and we're really happy with what it is, but COVID was certainly an issue for us, and I have to say with any evidence-based programs, there's a lot of requirements as far as keeping your certification and sometimes that can be a challenge in a rural state as much flexibility as we can have is really helpful.

And sometimes there's a tension between that. We want people to be certified and have the highest fidelity and quality of instruction as possible. But also, we like flexibility from our national holder license holder as well, that sometimes things happen, right? In North Dakota we might have to cancel a class because of a winter storm, those types of things. And so, you have to do so many classes a year to stay certified, and so we would have to juggle some of those requirements.

In North Dakota, we are offering workshops across the state for people to participate in and they're in-person. But in more recent years, there is a virtual option now for delivering the Stepping On program. We've had some interest with some of our facilitators. It requires some additional training. Obviously, there are safety concerns when we're doing this virtually. And our facilitators need to make sure those participants who are in their home are in a safe location, and they don't trip doing some of the exercises and those types of things. But it is available virtually, and I think that's one of the areas that we will no doubt be moving into in North Dakota.

Andrew Nelson: Gotcha. Earlier, I think you mentioned that many program participants had checked out their homes to see if there were changes that needed to be made in order to make things safer and reduce the risk of a fall. Can you tell us a little bit about some of the ways in which home modification can help to prevent injuries?

Jane Strommen: Oh, absolutely. We talked about how important it is to have accessible homes and that's one thing, but there are also major home modifications that somebody can do to make it a better environment for them. But there are also more minor home modifications that can be done. Simple things are making sure that you have proper lighting. Do you have lighting at the top of the stairs and the bottom of the stairs? Do you have nightlights that come on automatically as it starts to be dusk and nighttime so that you don't have to get up in the middle of the night and trip on something? Do we have handrails on both sides of any stairs? Not just on one side.

And if we have rugs, they should be non-skid non-slip rugs so that no one slips on that. We look at clutter, when we think about the clutter that you might even have in your living room with piles of magazines and papers on the floor and electrical cords and all of that, making sure your pathways are clear so that when you get up, you don't trip on something. We stress too, bathrooms, having grab bars where you need them by the commode, by the shower, by the bathtub, having a shower chair that, so that somebody can sit down with the handheld shower head, and then maybe the non-skid matting on the floor of the bathtub so that you can reduce those kinds of trips. But those are just really simple things. We have a home safety assessment that we go over in class, and we ask the participants to take this home, do an assessment of your home, your garage, your yard, and come back and share it with us. “What did you find?”

There's a stat out there, about 90% of older adults want to stay in their own home and their community as they age. And we know that there are multiple risk factors for falling, and there are things that we can do to lower somebody's risk for falls. And many of the things we talked about, the home safety assessment, being stronger, having better balance, checking your medications, making sure your vision is good. And those things are things that are within our control. And so, falls in 2020 in North Dakota was a leading cause of injury related deaths. And when we think about that, that's a very serious statistic. And that we should be doing everything that we can to help older adults be safe, have the best quality of life that they can, they want to age in their home, in their community.

Andrew Nelson: For sure. Are there any partnerships that you've formed to increase Stepping On's impact and reach?

Jane Strommen: Yes. There's that key partnership that we have in North Dakota is that the North Dakota Department of Health and Human Services has a division called the Division of Aging Services. And the Division of Aging Services receives some federal money that is earmarked for health promotion programs for older adults. And we have a contract with the Division of Aging for some of these dollars that really helps cover the costs. And that partnership with the Division of Aging is critical. The contract dollars cover the cost of us training new people in the state to be class leaders so that they can offer this in more communities. And it also covers some of the class expenses. We purchase ankle weights for participants so that they can have them when they're practicing their strength exercises. They come once a week for seven weeks, and we provide a healthy snack when they're there for their two-hour time.

And so some of those are required by the program, but those costs are all covered by the Division of Aging Services through that contract. We're so blessed in the state to have that funding because it would be challenging for a lot of these organizations across the state to send their staff to training, if they had to pay an expensive registration fee. And our grant also covers the travel-related costs for people to come to the training. And so it has been a big factor in North Dakota for the program to grow. We have a lot of other partners in the state too, that say, “This is important and we're going to send our staff to be trained because we want to be able to offer this.”

We have a great partnership, and I'll just use one example, but there's so many. We have the First District Public Health Unit, in the north-central part of the state that they've committed to get their public health nurses trained to deliver this program. And they have multiple counties, and they want to be able to offer this program in every one of their counties. And so we've had really great partnerships with lots of organizations. And of course, within Extension, we have some of our county family community wellness agents who have been trained as well. It needs to be co-led, so they partner with other professionals within their community to offer this program.

If other community leaders and organizations are interested in fall prevention and taking part of the Stepping On Program, the national license holder is called the Wisconsin Institute for Healthy Aging, and the acronym is WIHA. And you can go to their website, and you can look at all of the information about the Stepping On program. There's contact information if you would like to be involved find out how you could get people trained in your state.

One of the things that we are certainly evaluating is being able to offer Stepping On virtually. So I think that is one thing that we'll be looking at. The second thing would be looking at, where could it expand to? We have quite a few different communities offering it now, but there's still an opportunity for many other communities to have this program available to them. So really recruiting people in other communities across the state so that it can be more broadly available to older adults in our state.

Andrew Nelson: You've been listening to Exploring Rural Health, a podcast from RHIhub. In this episode, we spoke with Amy Rosenfeld, Senior Research Director of the NORC Walsh Center for Rural Health Analysis, along with Jessica Dayton, executive director of the Chautauqua Safety Village, and Dr. Jane Strommen oversees North Dakota State University's implementation of the Stepping On Program. Look in our show notes for more information about their work and visit for all things pertaining to rural health.