Record of the circumstances of falls in the community: perspective in the Iberian Peninsula

ABSTRACT Objective: to determine the diagnosis of the situation regarding documentation of falls and risk of falls in people older than 75 years in basic health units in Spain and Portugal. Method: mixed exploratory study in two stages: (i) quantitative descriptive of randomly selected fall records produced in one year (597 records; 197 Spanish and 400 Portuguese); and (ii) qualitative, with the purpose of knowing the perception of health professionals employing semi-structured interviews (72 professionals, 16 Spanish and 56 Portuguese). The study areas were two basic health units in southern Spain and northern Portugal. Results: in the fall records, the number of women was higher. The presence of fall was associated with the variables age, presence of dementia, osteoarticular disease, previous falls and consumption of antivertiginous medication. Health professionals perceived an absence of risk assessment instruments, as well as lack of prevention programs and lack of awareness of this event. Conclusion: falls are perceived as an area of priority attention for health professionals. Nonetheless, there is a lack of adherence to the registration of falls and risk assessment, due to organizational, logistical and motivational problems.

In the case of Portugal, a systematic random sample of the total of records of people over 75 years of age from 11 BHUs belonging to the Agrupamentos de Centros de Saúde Porto Oriental (ACES) was used for sample selection. In total, a sample of 400 records was studied.
The statistical program to obtain the sample was In the qualitative step, the subjects of the study were healthcare professionals of the BHU included in the quantitative study. These subjects were, according to the structure of the BHU, mainly nursing and medical professionals. Sampling was intentional, selected by institutional intermediaries, and determined by data saturation. Thus, the number of health professionals in Spain was 16 (8 nurses and 8 doctors), while in Portugal, an intentional sampling was also carried out among nurses, totaling 56 professionals. The lower number of health professionals in Spain was due to the simultaneous use of the questionnaire with focus groups (7) ; while in Portugal only questionnaires were used.  In the qualitative phase, the data of the selected health professionals were obtained through a questionnaire divided into two parts: sociodemographic variables The data of the qualitative step were analyzed through Bardin's analysis of thematic content (Bardin, 2009) to determine the "meaning cores" that form a message and whose presence or frequency can be significant for the analytical objective chosen (8) . In order to provide methodological rigor, the analysis was performed in three stages: (i) pre-analysis: reading of all the information to obtain a general information of the content; (ii) exploration of the material: coding information using "registration units" that establish a set of topics and a subsequent condensation of these themes into thematic categories; and (iii) treatment of results/ interpretation: presentation of the results in the form of summary tables that allow the interpretation and inference of the results with extracts from the "registration units".
The data obtained from the two study scopes were compared by data triangulation, techniques, methods and researchers.
The open answers to determine the potential barriers in the evaluation and intervention of the falls/fall risk were variable, however, similar data were obtained in both scopes.
More than two-thirds of respondents in both scopes (Spain:

Meaning units Thematic category
There is no specific icon or fall instruments in the registration system (SHP3) Lack of fall risk assessment instruments

Discussion
The present study provides evidence both quantitatively and qualitatively of the documentation problems of falls and risk of falls of people older than 75 years in basic health units in Spain and Portugal.
In both contexts, health professionals express that the fall is a problem of great relevance and that it is increasing due to the aging population. Nevertheless, in the studied registries it was shown the reduced number of documented falls. The causes that emerged from this absence of records were the lack of computer systems and friendly instruments that facilitate registration, work overload, as well as lack of awareness and motivation/ awareness in assessing the risk of falls.
However, the quality of the recorded data will determine the success in patient safety (9)(10)(11) . In this line, several studies showed reasons similar to those raised in our study, of the causes of underreporting (12)(13)(14) . This last author agrees with the perception of the Spanish and Portuguese health professionals of the present study, who report on the existence of events with serious injuries, but, on the other hand, there is no awareness that the system has a low registration rate, as it can be deduced from the fact that not many events with minor injuries or without consequences are included (14) .
Regarding the causes of fall, although no statistical significance was found in both contexts, the clinical records show that the majority of the falling elderly are female. Other studies also found a greater predisposition in females (16) , explaining this difference due to musculoskeletal and hormonal characteristics, as well as because they perform multiple tasks. In fact, the presence of osteoarticular diseases in people who fell was significantly more common (76.4%) than in those who did not suffer any falls (44.6%), a fact that also coincides with other similar series (16) . Therefore, it is essential to develop adjusted preventive measures, not only in relation to age -a significant variable in our study, but also to gender (17) . Statistical significance was also found for the The qualitative phase of the study also emphasizes that the preventive approach in the elderly is addressed exclusively by the nursing staff. In both contexts, some health professionals did not perceive the fall risk approach as a primary and priority prevention, focusing exclusively on the treatment of the consequences of falls (22) . In this sense, the nursing records related to the diagnosis and interventions were very scarce, evidencing a lack of awareness of the fall (23) . This is in accordance with similar series carried out in a hospital setting, where the prevalence of the diagnosis of risk of falls was 4% (24) . On the other hand, a study carried out by this research group (7) highlights the lack of registration culture at the level of the health professional and the institution itself, which may be associated with the Iberian culture itself. Therefore, the development of studies regarding the cultural factor in the risk of falling in the elderly is necessary in future studies.
The triangulation of data allowed us to identify several problems that need to be addressed by primary care centers in order to be able to develop appropriate preventive measures, and thus, ensure patient safety. In a technological society such as today's, it is necessary to develop user-friendly and accessible registration systems (24) .

Conclusions
The falls in the elderly living in the community are perceived by Spanish and Portuguese health professionals as an area of priority attention. However, the assessment of the risk of falling is generally not considered, as being a consequence of organizational, logistical and motivational factors.
The problems identified emerge in a considerable extent due to lack of adherence to the registry, perceived in a similar way in two distinct areas of the Iberian Peninsula.
In this sense, the cultural factor can be the common variable to the lack of record of the risk of falling and the circumstances of the fall.
Considering the nature of our study, it is necessary to take awareness measures and sensitize the multidisciplinary team of the primary care centers through training sessions, as well as carry out organizational modifications focused on protocols and computer systems of data collection.