Archives of Gerontology and Geriatrics
30 (2000) 25 – 34
www.elsevier.com/locate/archger

Effectiveness and acceptability of a newly
designed hip protector: a pilot study
Daniel K. Chan a,*, Gary Hillier b, Michelle Coore b,
Rosemary Cooke b, Rebecca Monk b, Janette Mills c,
Wai T. Hung d
a

Department of Geriatric Medicine, Prince of Wales Hospital, High Street, Randwick 2031,
NSW, Australia
b
Aged Care Assessment Team, Community Health Ser6ices, Orange, NSW, Australia
c
Department of Orthopaedics, Prince of Wales Hospital, High St., Randwick 2031, NSW, Australia
d
FAR, School of Mathematical Sciences, Uni6ersity of Technology, Broadway 2007, NSW, Australia
Received 6 September 1999; received in revised form 11 October 1999; accepted 13 October 1999

Abstract
Hip fracture has a signiﬁcant economic and personal cost, involving hospital admission
and functional impairment for elderly people. To assess the beneﬁt of using a newly designed
hip protector (new material and new design) to prevent fracture in a realistic setting, a
randomised intervention-control design was used to trial the effectiveness of pads worn by
high falls risk residents (n= 71) in nursing home for 9 months. 40 residents were in the
intervention group and 31 were in the control group. A proﬁle of falls, including time of day,
and orientation was obtained to demonstrate the potential effectiveness of the protectors for
injury prevention. Acceptance of the hip protector was also surveyed amongst nursing home
staff and residents. One hundred and one falls and six fractures occurred in the control
group. In contrast, one hundred and ninety one falls and three fractures occurred in the hip
protector (pads) group. The three fractures in the protector wearing group occurred when
pads were not in place. This was extrapolated as 1 in every 16.8 falls and 1 in every 63.7 falls
resulting in fracture in the two groups, respectively. The relative risk of fracture was 0.264
(95% CI=0.073–0.959) when the fracture incidence rate in the intervention group (three
fractures per 191 falls) was compared to the control group (six fractures per 101 falls). This
is a statistically signiﬁcant result and implies that this newly designed hip protector is

* Corresponding author. Tel.: +61-2-93824242; fax: + 61-2-93824241.
E-mail address: d.chan@unsw.edu.au (D.K. Chan)
0167-4943/00/$ - see front matter © 2000 Elsevier Science Ireland Ltd. All rights reserved.
PII: S 0 1 6 7 - 4 9 4 3 ( 9 9 ) 0 0 0 4 8 - 5

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D.K. Chan et al. / Arch. Gerontol. Geriatr. 30 (2000) 25–34

effective in preventing hip fracture. The majority of falls occurred during the day, which was
when protectors were worn in this study, but the data on orientation was incomplete, with
direction unknown in 74% of falls. Compliance was an issue, which was interpreted as only
50.3% of falls recorded with protectors in place. Dementia was identiﬁed as the explanation
for this as the pads were often removed by these residents who comprised the majority of
participants. Perception of low risk was the primary barrier to residents accepting the
intervention. Comfort of protectors was not a signiﬁcant concern for staff or residents, and
only staff described appearance as an issue. In conclusion, the newly designed hip protector
is protective against fractures in a realistic setting. Compliance and acceptance of the
protectors will ultimately determine the viability of this prophylaxis. © 2000 Elsevier Science
Ireland Ltd. All rights reserved.
Keywords: Novel hip protector; Hip fracture; Dementia

1. Introduction
Fracture of the hip has been recognised as a signiﬁcant problem in the elderly
population from both an economic perspective, and in terms of the personal impact
on the individual experiencing the injury. The impairment in function associated
with the fracture, and surgical intervention alters the lives of individuals, increasing
the likelihood of permanent institutionalisation ﬁve times for previously community
dwelling elderly (Cumming et al., 1996). Pre-fracture levels of physical functioning
are not regained by more than half the injured patients, and fractured neck of
femur increases mortality in the elderly signiﬁcantly (Butler et al., 1996; Fox et al.,
1996).
In the majority (60 – 90%) of fractures direct trauma is the aetiology (Cummings
and Nevitt, 1989), which indicates the importance of addressing falls in the elderly.
However, this is a complex issue as most falls are multifactorial in cause, including,
lower limb weakness, gait instability, vision, cognitive and functional impairments
as well as the effects of medication (Rubenstein et al., 1994). External factors have
been found to be unreliable determinants of risk, as multiple hazards have been
implicated in fractures (Clemson et al., 1996). Therefore, the value of a secondary
prophylaxis is suggested as a fracture prevention, to mediate the impact of the fall,
when it inevitably occurs.
Hip fracture risk is known to be reduced by a larger body mass index as
increased soft tissue appears to absorb the impact of a fall and protect the femur
(Hayes et al., 1991; Robinovitch et al., 1995). Even in a direct fall onto the hip in
the elderly, research has shown that natural padding is insufﬁcient to attenuate the
force, and other mechanisms such as reﬂex contraction of the quadriceps protect
the hip fracture (Robinovitch et al., 1995).
As a solution to the prevention of fracture, several clinical trials have demonstrated that external hip protector is effective in protecting the hip, as no fractures
occurred in subjects while wearing the appliances (Lauritzen et al., 1993; Tracey et
al., 1998). However, the compliance rate is only about 50% (Lauritzen et al., 1993;
Tracey et al., 1998) and it drops to about 30% (Tracey et al., 1998) in the long term.

D.K. Chan et al. / Arch. Gerontol. Geriatr. 30 (2000) 25–34

27

The design of these hip protectors are such that they have to be worn with
underpants to cover a small area over the greater trochanter. Any movement of the
protector may mean that the covering position may be shifted. Therefore, the hip
protectors are quite tightly ﬁtted and this may explain a signiﬁcant proportion of
people feeling the discomfort (Tracey et al., 1998). Furthermore, the polypropylene
material used is quite hard which may add to the discomfort.
We therefore designed a new hip protector using softer material, which is ﬁtted
to the inner surfaces of trousers or tracksuit pants. The hip protectors also cover
the greater trochanters but have the propensity to allow for some movement, and
hence may cause less discomfort. Our aims are to ﬁnd out both the effectiveness
and acceptability of this newly designed hip protector.

2. Patient and method

2.1. Participants
Subjects were drawn from nine nursing homes and the criteria for inclusion was
that the nursing home staff identiﬁed the residents as high falls risk. This was not
on the basis of particular diagnosis, or any formal evaluation of falls risk, but the
perception of the staff themselves. The subjects or the person responsible was then
asked to sign consent to participate. Therefore, the purposes of the study were clear
to participants and/or the guardians, and involvement was voluntary. Random
assignment of subjects was achieved in most nursing homes with some participants
designated as control and some to wear the protectors. The current results are
based on 71 participants (control =31, treatment= 40) on whom data has been
collected after 9 months.

2.2. Hip protector
The hip protectors were designed to absorb the impact in the upper femur, hip
region, in particular to cover the greater trochanter in a fall. They are made of pads
as shown in Fig. 1. The pads are worn in pockets sewn into the inner surfaces of
tracksuit pants or trousers. Pads are 2× 3 rows of cube shapes with dimensions 6
(width) ×7 (length)× 2.5 (depth) cm in each cube. The material is made from EVA
foam. This material is waterproof and the shock absorbency is demonstrated
through the successful use in Tai Kwan Do matting. The mould used is also jointed
allowing ﬂexibility and comfort. Therefore, this new hip protector is different from
that by Lauritzen (Lauritzen et al., 1993) in both material and design.

2.3. Measurement
2.3.1. Effecti6eness of protectors
A simple form was designed for inclusion in residents ﬁles which staff were asked
to complete for every fall. Important information, which would indicate the

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D.K. Chan et al. / Arch. Gerontol. Geriatr. 30 (2000) 25–34

effectiveness of the protector, was injuries, orientation of the fall, and the time of
day, as protectors were not worn at night in bed in this current study.

2.3.2. Acceptance of protectors
Compliance was extrapolated from the percentage of falls recorded for which
protectors were worn.
Separate surveys were designed for staff and residents, with closed responses to
enhance acceptability to nursing staff in terms of time constraints. However, the
survey was administered verbally and response options were not designed to
quantify responses, but facilitate those actually using the protectors to articulate
their opinion of their acceptability.
2.4. Data analysis
The calculation of the fracture incidence rate ratio (or relative risk) was as
follows:three fractures per 191 falls (hip pad group)/six fractures per 101 falls
(control group).This is based on the test-based method by Sahai and Khurshid
(Sahai and Khurshid, 1996).

Fig. 1. (a) The structure of the hip protector. (b) The appearance of the patient with hip protector.

D.K. Chan et al. / Arch. Gerontol. Geriatr. 30 (2000) 25–34

29

Fig. 1. (Continued)

3. Results

3.1. Effecti6eness of protectors
Fifty of the 71 subjects had fallen with a total 292 falls recorded. Nine fractures
occurred with none of the eight residents wearing protectors at the time of injury
(one resident fractured both hips 1 month apart). 101 of the falls and six of the
fractures were recorded in the control group. This may be interpreted as a risk of
1 in every 16.8 falls resulting in a hip fracture. The protector group in comparison
accounted for three of the fractures and 191 of the falls with an extrapolated
fracture risk of one in every 63.7 falls. The relative risk of fractures in the hip
protector group as compared with the control group was 0.264 (95% CI= 0.073–

D.K. Chan et al. / Arch. Gerontol. Geriatr. 30 (2000) 25–34

30

0.959). The average falls for control, protector, total and fracture groups is shown
in Table 1.
The orientation of falls for those resulting in fractures was that three were
unknown, one was backwards, and ﬁve were sideways. All occurred during the day.
In the total study group 81.8% of falls occurred during the day (6:00–22:00 h)
and 9.6% were sideways. As 74% of falls were of unknown orientation, it is possible
that the protectors may have been more useful in mediating impact than indicated.
A proﬁle of falls (orientation and time) is shown in Fig. 2.

3.2. Acceptance of protectors
3.2.1. Compliance
In this study, compliance was deﬁned as the percentage of falls recorded for
which hip protectors were worn in the treatment group. The compliance of the
participants was 50.3%.
In the staff survey dementia was indicated as the reason for non-compliance.
64.8% of the total 71 participants have been identiﬁed as having dementia.
3.2.2. Perceptions of protectors
The surveys were administered to seven staff and four residents. As most
participants were diagnosed with dementia this limits the reliable resident sample.
Three of the residents surveyed had been nominated as suitable for the study, but
declined to participate. Comments from staff and residents noted informally have
also been documented.
3.2.3. Comfort
Only one staff member noted concern about the comfort suggesting the seams on
adapted underwear had rubbed. Also only one resident had serious concerns
regarding the protectors highlighting the bulkiness and awkwardness, especially
when continence pads are already worn. The tracksuit pants were also an issue for
hot weather, so alternative clothing ﬁtted with the protectors was preferred.

Table 1
Summary table of falls and fractures data
Control
Falls
Residents
Average falls per resident
Fractures
a

Treatment

Combined

Fracture group

101
31
3.26
6

191
40
4.78
3

292
71
4.11
9

32
8a
4

One resident had two fractures (one on each side).

D.K. Chan et al. / Arch. Gerontol. Geriatr. 30 (2000) 25–34

31

Fig. 2. Proﬁle of fall (orientation and time).

3.2.4. Cost
Since a pair of protectors cost only $10.00 AUD ($30 with tracksuit pants), no
one was unable to afford it.
3.2.5. Appearance
Fifty seven percent of staff described this as concern. However, no residents
indicated it was an issue. The obvious bulkiness of the protectors was noted, and
one staff member commented public dignity was compromised, such as at a doctors
appointment.

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D.K. Chan et al. / Arch. Gerontol. Geriatr. 30 (2000) 25–34

3.2.6. Barriers to acceptance
Two of the staff indicated they would have serious concerns regarding the use of
protectors in resident management. The reasons suggested included, hygiene and
the inconvenience of putting them on, especially when resident non-compliance was
an issue. Enthusiasm for the protectors appeared to have a direct relationship with
perceived effectiveness, as one staff member was sufﬁciently convinced by their own
observation of the protectors, that they would like to continue their use beyond the
study. Another respondent indicated that implementation of the protectors would
ultimately depend on resident feelings.
Residents explanations for not using the protectors centred on a perceived lack of
personal risk. This included the belief in the two respondents already post fracture,
simply that as they had experienced one fractured hip, they were now safe, and an
indication from the doctor that the ﬁrst fracture was pathological, therefore the
resident felt external protection would be of no beneﬁt in preventing fracture.
Another resident noted that she had ridden horses for years, and would have
needed them more then, as would other people in higher risk occupations, than
simply being in danger of falling. Independence to manage their own risk was also
an issue as one resident felt she was now too old to care, and another asserted the
right to refuse intervention and experience the consequences of their own decision.
The one resident surveyed who was wearing the protectors queried the position of
the protectors for effectiveness, but was otherwise satisﬁed with the intervention.
His daughter actually commented on the peace of mind provided by knowing he
was wearing the protectors.

4. Discussion
Ultimately the aim of this study was to implement protectors in a realistic setting
and record data as to their effectiveness. This data has supported the value of pads
worn to prevent fracture of the hip as no fractures occurred while they were in
place. Furthermore, the reduction of relative risk of hip fracture in this new hip
protector (RR= 0.264) is comparable or marginally better than the old design
(RR =0.44) by Lauritzen (Lauritzen et al., 1993). As most falls occurred during the
day, this suggested that current wearing regime should be sufﬁcient, it is the actual
compliance with wearing the protectors that is problemsome. 50.3% is a low
compliance, even allowing for the minority of falls occurring at night when the
protectors were not worn (i.e. compliance rate is actually higher if night time falls
are excluded from the calculation). However, this compliance rate is consistent with
other designs of hip protectors (Lauritzen et al., 1993; Tracey et al., 1998).
Dementia is the most signiﬁcant factor in this study regarding compliance, which is
an area that perhaps should be addressed in the design of the pads so they are not
able to be removed easily and are less obvious to the person as their presence
appears to irritate these residents.

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33

Unfortunately the low compliance could also reduce the strength of the fracture
risk ﬁndings comparing the treatment and control groups. Although compliance
was related to dementia in this research, the surveys regarding acceptance have
gauged the importance of attitudes to the protectors in actually implementing them
as an intervention tool.
As for the perception and acceptance survey, the sample used was small,
especially of residents. However, the diversity of responses even in this group
suggests the difﬁculty of assessing attitudes and marketing the protectors to the
consumer. In terms of staff it is interesting that they accorded more concern
regarding the appearance of the protectors than the residents. It is the actual
perception and understanding of fracture risk that appears to be the central barrier
to acceptance amongst residents. This supports the value of education to the elderly
who are high risk, such as frequent fallers or post fracture clients, in understanding
the risk not simply of falling, but of fracture (Cameron and Quine, 1994).
Therefore, the preferred management of the problem of fractured neck of femur
would include not just falls prevention but fracture protection.
The ﬁndings of this study were limited to a nursing home population where
protectors have had been implemented and monitored by staff. Therefore, issues
such as ease of use for the client have not been explored which could be a
signiﬁcant difﬁculty for community living elderly with mobility impairments. A
similar study using community living individuals would be appropriate, not to
validate the actual effectiveness of protectors but their practicality.
In terms of the participant group selected as suitable for the research the
variables were not monitored by the researcher, it was based on the subjective
opinion of staff. However, the comparison in the average falls per year per bed of
1.5 in institutions to the 4.11 recorded for this group in a 9-month period, suggests
that staff are accurate in determining high falls risk residents. Another point of note
is the higher rate of fall (4.78 falls per bed per 9 months) in treatment group
compared to controls (3.26) may be due to willingness of staff to allow patients to
ambulate after they are put on hip protectors (rather than restricting them).
The hip fracture per fall rate in the control group is 5.94% (six fractures in 101
falls). This is considerably higher than fracture rates of elderly in the community
but is in accord with ﬁndings from Butler et al. (Butler et al., 1996) (the risk of hip
fracture in institutions is 101.5 times those living in private homes).
Since a lot of the fallers are demented people whose rehabilitation and functional
outcome after a fracture hip is poor, this raises the ethical question as to their rights
to choose or deny wearing the hip protectors. As our study actually includes proxy
consent from carers or guardians, this raises the important question as to whether
the important information about hip protectors should be focused on carers or
guardians, not just elderly fallers.
The price of a pair of protectors is only $10.00 AUD, making it possible to be
affordable to nearly all pensioners. Cost was a concern in some other protectors
(Cameron and Quine, 1994).

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5. Conclusion
The descriptive data about falls and fractures in a realistic trial in nursing homes
indicates the viability of protectors as a valid instrument in the prevention of
fractured hips as none occurred while the device was in place. However, further
information regarding the proﬁle of falls, especially direction of fall, would increase
the evidence for the potential effectiveness of this device. Potential barriers to
implementation include compliance, and attitudes to perceived risk.

Acknowledgements
The authors express their gratitude and thanks to Calare Nursing Home, Orange;
Cudal Memorial Hospital; Eugowra Memorial Hospital; Mater Misericordiae
Nursing Home, Forbes; Moyne Eventide Home, Canowindra; Niola Nursing
Home, Parkes; Wontama Nursing Home, Orange; Sir Joseph Banks Nursing
Home, Botany; Camelot Nursing Home, Maroubra for their co-operation and help.

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